Provider Demographics
NPI:1215028261
Name:THIEDE, LAURIE J (PT-A)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:THIEDE
Suffix:
Gender:F
Credentials:PT-A
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:J
Other - Last Name:BARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT-A
Mailing Address - Street 1:1300 EGG HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1277
Mailing Address - Country:US
Mailing Address - Phone:920-746-0410
Mailing Address - Fax:
Practice Address - Street 1:323 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1401
Practice Address - Country:US
Practice Address - Phone:920-743-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1316-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40249300Medicaid
526526Medicare ID - Type Unspecified