Provider Demographics
NPI:1497884365
Name:THESEN, GWEN D (ATC)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:D
Last Name:THESEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 CANNON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15218-2109
Mailing Address - Country:US
Mailing Address - Phone:412-273-1923
Mailing Address - Fax:
Practice Address - Street 1:7710 CANNON ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15218-2109
Practice Address - Country:US
Practice Address - Phone:412-273-1923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA02-18412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer