Provider Demographics
NPI:1487026753
Name:THIELE, ZACHARY (ATC)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:THIELE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1892 COUNTY ROAD 51
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IN
Mailing Address - Zip Code:46793-9750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1892 COUNTY ROAD 51
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IN
Practice Address - Zip Code:46793-9750
Practice Address - Country:US
Practice Address - Phone:260-438-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001964A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer