Provider Demographics
NPI:1356302756
Name:THEISEN, TARA H (DC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:H
Last Name:THEISEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 W GALENA AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-3819
Mailing Address - Country:US
Mailing Address - Phone:815-232-2225
Mailing Address - Fax:815-233-2571
Practice Address - Street 1:1019 W GALENA AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-3819
Practice Address - Country:US
Practice Address - Phone:815-232-2225
Practice Address - Fax:815-233-2571
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU75603Medicare UPIN
IL210083Medicare PIN