Provider Demographics
NPI:1114185832
Name:THIEL, ANGELA S (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:THIEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:S
Other - Last Name:KONRATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1065 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3567
Practice Address - Country:US
Practice Address - Phone:815-588-1366
Practice Address - Fax:815-588-2010
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-015115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00865614OtherMEDICARE RR
ILP00865614OtherMEDICARE RR
IL205782015Medicare PIN
IL202845010Medicare PIN
IL211082012Medicare PIN
IL212608009Medicare PIN