Provider Demographics
NPI:1992484125
Name:THIEL, ALEXANDRA M
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:M
Last Name:THIEL
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 1:58 POMPERAUG ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798
Mailing Address - Country:US
Mailing Address - Phone:203-313-5537
Mailing Address - Fax:
Practice Address - Street 1:58 POMPERAUG ROAD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:09798-3713
Practice Address - Country:US
Practice Address - Phone:203-313-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1687103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst