Healthcare Provider Details

I. General information

NPI: 1386701548
Provider Name (Legal Business Name): CAROL ANN THIELE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL ANN KELLCIK

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 11/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 STADIUM DR
BOULDER CO
80309-0001
US

IV. Provider business mailing address

5450 WESTERN AVE
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-315-9900
  • Fax: 303-315-9902
Mailing address:
  • Phone: 303-315-9900
  • Fax: 303-315-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPTL.0001914
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0001914
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: