Provider Demographics
NPI:1386701548
Name:THIELE, CAROL ANN (PT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:THIELE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:KELLCIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-315-9900
Mailing Address - Fax:303-315-9902
Practice Address - Street 1:2150 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-0001
Practice Address - Country:US
Practice Address - Phone:303-315-9900
Practice Address - Fax:303-315-9902
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.00019142251S0007X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98807226Medicaid