MEDICARE: AMYLYNN THEISEN MA, LPC, CAADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6401006678	MI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	C-01471	MI

General Provider Information

NPI Number	:	1821260696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMYLYNN THEISEN MA, LPC, CAADC

Provider Business Mailing Address
First Line	:	121 N LANSING ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-1631
Country	:	US
Telephone Number	:	989-944-2950
Fax Number	:	989-317-3638

Provider Business Practice Location Address
First Line	:	1205 S MISSION ST
Second Line	:	STE 27
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-3939
Country	:	US
Telephone Number	:	989-944-2950
Fax Number	:	989-317-3638

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	01/09/2017

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