Provider Demographics
NPI:1881572162
Name:THIELS, MYLISA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MYLISA
Middle Name:
Last Name:THIELS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 RAMBLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-8290
Mailing Address - Country:US
Mailing Address - Phone:903-280-5867
Mailing Address - Fax:
Practice Address - Street 1:2301 RAMBLEWOOD RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-8290
Practice Address - Country:US
Practice Address - Phone:903-280-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR203222235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty