Provider Demographics
NPI:1104850593
Name:THIEL, KILEY COSTNER (LCMHCS)
Entity Type:Individual
Prefix:MRS
First Name:KILEY
Middle Name:COSTNER
Last Name:THIEL
Suffix:
Gender:F
Credentials:LCMHCS
Other - Prefix:
Other - First Name:KILEY
Other - Middle Name:A
Other - Last Name:COSTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 E 7TH ST STE 6
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2455
Mailing Address - Country:US
Mailing Address - Phone:704-756-3623
Mailing Address - Fax:
Practice Address - Street 1:1501 E 7TH ST STE 6
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2455
Practice Address - Country:US
Practice Address - Phone:704-756-3623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103051Medicaid