Provider Demographics
NPI:1407386709
Name:THIELS, DWAYNE THOMAS
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:THOMAS
Last Name:THIELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 ANGELINA CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-5378
Mailing Address - Country:US
Mailing Address - Phone:386-214-7831
Mailing Address - Fax:
Practice Address - Street 1:829 ANGELINA CT
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-5378
Practice Address - Country:US
Practice Address - Phone:386-214-7831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst