Provider Demographics
NPI:1922819168
Name:THELEN, MARIAH ELIZABETH (COTA/L)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:ELIZABETH
Last Name:THELEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PEWAMO
Mailing Address - State:MI
Mailing Address - Zip Code:48873-5109
Mailing Address - Country:US
Mailing Address - Phone:989-640-9587
Mailing Address - Fax:
Practice Address - Street 1:620 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811-9790
Practice Address - Country:US
Practice Address - Phone:989-584-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202010245224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant