Provider Demographics
NPI:1720425465
Name:THIELE, CARISSA LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:LYNN
Last Name:THIELE
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Gender:F
Credentials:MS, CCC-SLP
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Mailing Address - Street 1:390 E CONGRESS PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6202
Mailing Address - Country:US
Mailing Address - Phone:815-477-4788
Mailing Address - Fax:815-477-4790
Practice Address - Street 1:390 E CONGRESS PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6202
Practice Address - Country:US
Practice Address - Phone:815-477-4788
Practice Address - Fax:815-477-4790
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL146010746235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist