Provider Demographics
NPI:1245567544
Name:THIELE, DONNA (SLP-A)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:THIELE
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 EMERY STRREET
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250
Mailing Address - Country:US
Mailing Address - Phone:207-353-9009
Mailing Address - Fax:
Practice Address - Street 1:74 ROCK RIDGE RUN
Practice Address - Street 2:KIMBERLY A. EGBERTS & ASSOC
Practice Address - City:CUMBERLAND CENTER
Practice Address - State:ME
Practice Address - Zip Code:04021
Practice Address - Country:US
Practice Address - Phone:207-829-4763
Practice Address - Fax:207-829-4763
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESAS17192355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432814800Medicaid