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General NPI Number Information
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NPI Number | 1740225176
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Entity Type | Individual
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Provider Name | KIMBERLY MARIE GYDISH-THEOBALD M.ED., L.M.H.C.,CAP
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Gender | Female
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Dates
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Enumeration Date | 06/19/2006
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Last Update Date | 05/06/2020
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Provider Practice Location Address
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Address Line | 1536 KINGSLEY AVE SUITE 126
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City | ORANGE PARK
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State | FL
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Zip | 32073-4587
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Country | US
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Telephone | 904-264-8311
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Fax | 904-264-8377
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Provider Business Mailing Address
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Address Line | 1536 KINGSLEY AVE SUITE 126
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City | ORANGE PARK
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State | FL
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Zip | 32073-4587
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Country | US
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Telephone | 904-264-8311
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Fax | 904-264-8377
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH7918
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License Number State | FL
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