Provider Demographics
NPI:1710519814
Name:THIELEN, AMANDA CATHERINE (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:CATHERINE
Last Name:THIELEN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 S GRAND AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5917
Mailing Address - Country:US
Mailing Address - Phone:310-528-4595
Mailing Address - Fax:
Practice Address - Street 1:740 S PLACENTIA AVE
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6832
Practice Address - Country:US
Practice Address - Phone:714-646-8318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist