Provider Demographics
NPI:1811409550
Name:THIEL, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:THIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1121
Mailing Address - Country:US
Mailing Address - Phone:937-328-5300
Mailing Address - Fax:937-322-4900
Practice Address - Street 1:623 S CENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-2209
Practice Address - Country:US
Practice Address - Phone:937-328-5300
Practice Address - Fax:937-322-4900
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161378101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)