Provider Demographics
NPI:1952596454
Name:THIEDE, BETTY L (RD)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:L
Last Name:THIEDE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 E 600 N
Mailing Address - Street 2:
Mailing Address - City:WINDFALL
Mailing Address - State:IN
Mailing Address - Zip Code:46076-9361
Mailing Address - Country:US
Mailing Address - Phone:765-860-0535
Mailing Address - Fax:574-223-2159
Practice Address - Street 1:2360 E 600 N
Practice Address - Street 2:
Practice Address - City:WINDFALL
Practice Address - State:IN
Practice Address - Zip Code:46076-9361
Practice Address - Country:US
Practice Address - Phone:765-860-0535
Practice Address - Fax:574-223-2159
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-09
Last Update Date:2007-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered