Individual
MRS. ELLEN MARIE THEOBALD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
5015 CANYON CREST DR, SUITE 203, RIVERSIDE, CA 92507
(951) 369-7416
(951) 787-9093
Mailing address
5307 STONEWOOD DR, RIVERSIDE, CA 92506
(951) 683-2684
(951) 683-2766
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PSY9953
CA
Other
Enumeration date
11/20/2006
Last updated
07/08/2007
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