Provider Demographics
NPI:1538340690
Name:MARY LYNN THIENEMAN
Entity type:Organization
Organization Name:MARY LYNN THIENEMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:THIENEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LMFT
Authorized Official - Phone:502-644-5433
Mailing Address - Street 1:POST OFFICE BOX 22816
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-0816
Mailing Address - Country:US
Mailing Address - Phone:502-644-5433
Mailing Address - Fax:502-814-3745
Practice Address - Street 1:8521 LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3800
Practice Address - Country:US
Practice Address - Phone:502-644-5433
Practice Address - Fax:502-814-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY08851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0644002Medicare PIN