Provider Demographics
NPI:1437437753
Name:THIBODEAU, ALYSSE ZITTNAN (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSE
Middle Name:ZITTNAN
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3001 HARBOR LN. N.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447
Mailing Address - Country:US
Mailing Address - Phone:763-551-3652
Mailing Address - Fax:763-551-1334
Practice Address - Street 1:3001 HARBOR LN. N.
Practice Address - Street 2:SUITE 120
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447
Practice Address - Country:US
Practice Address - Phone:763-551-3652
Practice Address - Fax:763-551-1334
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN452620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist