Provider Demographics
NPI:1376559716
Name:THIESSE, GLYNIS N (MS LP)
Entity Type:Individual
Prefix:
First Name:GLYNIS
Middle Name:N
Last Name:THIESSE
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 OAK ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3610
Mailing Address - Country:US
Mailing Address - Phone:218-829-7140
Mailing Address - Fax:
Practice Address - Street 1:617 OAK ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3610
Practice Address - Country:US
Practice Address - Phone:218-829-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4630103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6281371OtherMEDICA
MN62G75THOtherBCBS
MN848980OtherARAZ
MN115826Other115826