Provider Demographics
NPI:1942254719
Name:THIELEN, CRAIG LESLIE (PT)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:LESLIE
Last Name:THIELEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-833-5900
Mailing Address - Fax:319-833-5901
Practice Address - Street 1:1731 W RIDGEWAY AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4594
Practice Address - Country:US
Practice Address - Phone:319-833-5900
Practice Address - Fax:319-833-5901
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0492272Medicaid
IA17334OtherWELLMARK INS PLAN
IA0492272Medicaid