Provider Demographics
NPI:1154866408
Name:THIEL, LISA MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:THIEL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1205
Mailing Address - Country:US
Mailing Address - Phone:231-881-0766
Mailing Address - Fax:
Practice Address - Street 1:223 N PARK ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1220
Practice Address - Country:US
Practice Address - Phone:231-582-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801083768104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker