Provider Demographics
NPI:1477077691
Name:THIELE, DONNA K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:K
Last Name:THIELE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 DANTE CT STE 30
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-3847
Mailing Address - Country:US
Mailing Address - Phone:631-834-7600
Mailing Address - Fax:
Practice Address - Street 1:321 DANTE CT STE 30
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-3847
Practice Address - Country:US
Practice Address - Phone:631-542-2885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-30
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000057103K00000X
103T00000X
NY017221103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist