Provider Demographics
NPI:1609672286
Name:THEIS, MADISON JANE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:JANE
Last Name:THEIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1156
Mailing Address - Country:US
Mailing Address - Phone:419-806-9802
Mailing Address - Fax:
Practice Address - Street 1:3232 CENTRAL PARK W
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-3010
Practice Address - Country:US
Practice Address - Phone:567-201-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician