Provider Demographics
NPI:1518982354
Name:KILLEEN, THEA S
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:S
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5740 BROOKLYN BLVD
Mailing Address - Street 2:100
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:763-561-4045
Mailing Address - Fax:763-561-8690
Practice Address - Street 1:5740 BROOKLYN BLVD
Practice Address - Street 2:100
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:763-561-4045
Practice Address - Fax:763-561-8690
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3959111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U97992Medicare UPIN