Provider Demographics
NPI:1245359157
Name:THIESEN, FRED ANDREW (COTA)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:ANDREW
Last Name:THIESEN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:CALIFON
Mailing Address - State:NJ
Mailing Address - Zip Code:07830-4354
Mailing Address - Country:US
Mailing Address - Phone:908-832-1306
Mailing Address - Fax:
Practice Address - Street 1:47 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:CALIFON
Practice Address - State:NJ
Practice Address - Zip Code:07830-4354
Practice Address - Country:US
Practice Address - Phone:908-832-1306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09050700224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant