Provider Demographics
NPI:1699978577
Name:THIELE, MARY BETH (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARY BETH
Middle Name:
Last Name:THIELE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 S 30TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5955
Mailing Address - Country:US
Mailing Address - Phone:920-207-0333
Mailing Address - Fax:
Practice Address - Street 1:1235 S 24TH ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5516
Practice Address - Country:US
Practice Address - Phone:920-682-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2876-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist