Provider Demographics
NPI:1720625049
Name:THIELE, TARA L
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:THIELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-5850
Mailing Address - Country:US
Mailing Address - Phone:715-563-8790
Mailing Address - Fax:
Practice Address - Street 1:4076 KOTHLOW AVE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3090
Practice Address - Country:US
Practice Address - Phone:715-235-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
WI7668-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional