Provider Demographics
NPI:1851545099
Name:THIELEN, MARK ROBERT (MFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBERT
Last Name:THIELEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 WHITING ST.
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946
Mailing Address - Country:US
Mailing Address - Phone:530-271-7266
Mailing Address - Fax:530-477-7822
Practice Address - Street 1:698 WHITING ST
Practice Address - Street 2:SUITE D
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7568
Practice Address - Country:US
Practice Address - Phone:530-271-7266
Practice Address - Fax:530-477-7822
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45180106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist