Healthcare Provider Details

I. General information

NPI: 1528875937
Provider Name (Legal Business Name): INGRID ANNE THIES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 FM 2673
CANYON LAKE TX
78133-4510
US

IV. Provider business mailing address

1356 FM 2673
CANYON LAKE TX
78133-4510
US

V. Phone/Fax

Practice location:
  • Phone: 830-907-2145
  • Fax:
Mailing address:
  • Phone: 830-907-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1147807
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: