Provider Demographics
NPI:1063842946
Name:THELEN, AUDREY (COTA/L)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:THELEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-1007
Mailing Address - Country:US
Mailing Address - Phone:517-449-6872
Mailing Address - Fax:
Practice Address - Street 1:731 STARKWEATHER DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-1128
Practice Address - Country:US
Practice Address - Phone:517-323-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007426224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5202007426OtherMICHIGAN OCCUPATIONAL THERAPY ASSISTANT LICENSE