Provider Demographics
NPI:1407961113
Name:THIEL, SUSAN (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:THIEL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S BELLFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6235
Mailing Address - Country:US
Mailing Address - Phone:425-672-7007
Mailing Address - Fax:
Practice Address - Street 1:14350 SE EASTGATE WAY
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-6458
Practice Address - Country:US
Practice Address - Phone:206-205-8974
Practice Address - Fax:206-205-8969
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK83133V00000X
WADI00002012133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDT0083Medicaid