Provider Demographics
NPI:1518462282
Name:THIELE, CAITRIA (LAC, MSOM)
Entity Type:Individual
Prefix:
First Name:CAITRIA
Middle Name:
Last Name:THIELE
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 W JENNA DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-7600
Mailing Address - Country:US
Mailing Address - Phone:414-238-4511
Mailing Address - Fax:
Practice Address - Street 1:100 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1203
Practice Address - Country:US
Practice Address - Phone:414-238-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI953-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist