Provider Demographics
NPI:1750845772
Name:THIELKE, TAYLOR LEIGH (LMT)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:LEIGH
Last Name:THIELKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-2245
Mailing Address - Country:US
Mailing Address - Phone:920-459-9090
Mailing Address - Fax:
Practice Address - Street 1:4000 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-2245
Practice Address - Country:US
Practice Address - Phone:920-459-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12872-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist