Provider Demographics
NPI:1770198210
Name:THELEN, EMMA NICOLE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:NICOLE
Last Name:THELEN
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 1:3290 S HINMAN RD
Mailing Address - Street 2:
Mailing Address - City:WESTPHALIA
Mailing Address - State:MI
Mailing Address - Zip Code:48894-9209
Mailing Address - Country:US
Mailing Address - Phone:989-640-2718
Mailing Address - Fax:
Practice Address - Street 1:1524 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2933
Practice Address - Country:US
Practice Address - Phone:989-854-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X251S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251S00000XAgenciesCommunity/Behavioral Health