Basic Information
| Provider Information | |||||||||
| NPI: | 1487677829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEIS | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THEIS-HEDGE | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4314 YOAKUM BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770065818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138500049 | ||||||||
| FaxNumber: | 7136277302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4314 YOAKUM BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770065818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138500049 | ||||||||
| FaxNumber: | 7136277302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 25778 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 102775710 | 05 | TX | MEDICAID | 102775711 | 05 | TX | MEDICAID | 102775712 | 05 | TX | MEDICAID | 88186A | 01 | TX | BCBS TX HOUSTON | OTHER | 1025775701 | 05 | TX | MEDICAID | 102775702 | 05 | TX | MEDICAID | 102775704 | 05 | TX | MEDICAID | 102775705 | 05 | TX | MEDICAID | 102775707 | 05 | TX | MEDICAID | 102775709 | 05 | TX | MEDICAID | 102775708 | 05 | TX | MEDICAID | P00997619 | 01 | TX | RR MCR | OTHER | P01010614 | 01 | TX | RR MCR | OTHER | 102775706 | 05 | TX | MEDICAID | 88336A | 01 | TX | BCBS TX | OTHER | P00961151 | 01 | TX | RR MCR | OTHER | P01011570 | 01 | TX | RR MCR | OTHER |