Provider Demographics
NPI:1922546712
Name:THIEL, NICHOLAS (PTA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:THIEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19395 W CAPITOL DR
Mailing Address - Street 2:STE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2736
Mailing Address - Country:US
Mailing Address - Phone:262-923-7101
Mailing Address - Fax:262-923-7179
Practice Address - Street 1:N4231 STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-6130
Practice Address - Country:US
Practice Address - Phone:715-526-3158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2536-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant