Provider Demographics
NPI:1760803076
Name:THIEFAULT, ERIN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:THIEFAULT
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 1:6182 W LOFTY RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8599
Mailing Address - Country:US
Mailing Address - Phone:509-280-6116
Mailing Address - Fax:
Practice Address - Street 1:17121 E 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-8556
Practice Address - Country:US
Practice Address - Phone:509-924-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-05
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160069364225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant