Provider Demographics
NPI:1497737712
Name:THEILER, MARY JANE (MPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:THEILER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:RAINFORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:410 E 22ND ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2609
Practice Address - Country:US
Practice Address - Phone:402-721-3908
Practice Address - Fax:402-721-4047
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0586347Medicaid
NE6531OtherBLUE CROSS BLUE SHIELD
IA0586347Medicaid
NE6531OtherBLUE CROSS BLUE SHIELD
NER81525Medicare UPIN