Provider Demographics
NPI:1730833773
Name:THEOBALD, MARJORIE JANE (BCABA/LABA)
Entity type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:JANE
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:BCABA/LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TANGLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-3314
Mailing Address - Country:US
Mailing Address - Phone:434-282-4831
Mailing Address - Fax:
Practice Address - Street 1:9 PINNACLE DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2366
Practice Address - Country:US
Practice Address - Phone:804-915-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000371103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst