Provider Demographics
NPI:1578143798
Name:THEILL, KIRESTEN (SOCIAL WORKER)
Entity Type:Individual
Prefix:
First Name:KIRESTEN
Middle Name:
Last Name:THEILL
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 ELM ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-3679
Mailing Address - Country:US
Mailing Address - Phone:563-690-2850
Mailing Address - Fax:563-582-5335
Practice Address - Street 1:1690 ELM ST STE 300
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3679
Practice Address - Country:US
Practice Address - Phone:563-690-2850
Practice Address - Fax:563-582-5335
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IA101727104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1720146319Medicaid