Provider Demographics
NPI:1841380813
Name:THELEN, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:THELEN
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 1:7437 170TH PL
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4744
Mailing Address - Country:US
Mailing Address - Phone:708-373-2468
Mailing Address - Fax:708-620-5358
Practice Address - Street 1:7437 170TH PL
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-4744
Practice Address - Country:US
Practice Address - Phone:708-373-2468
Practice Address - Fax:708-620-5358
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004948225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3640571036046701Medicaid
IL209305Medicare ID - Type Unspecified
IL209306Medicare ID - Type Unspecified
IL3640571036046701Medicaid
IL205966Medicare ID - Type Unspecified