Provider Demographics
NPI:1427019900
Name:THIEDE, TAMARA S (PT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:THIEDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:SUE
Other - Last Name:GRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:1992 E STOP 13 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6267
Practice Address - Country:US
Practice Address - Phone:317-808-0230
Practice Address - Fax:317-808-0231
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001604A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01061937OtherMEDICARE RAILROAD
IN000000112030OtherANTHEM ID
IN100366850Medicaid
IN000000112030OtherANTHEM ID