Provider Demographics
NPI:1558725903
Name:THIESSE, ADAM (AT, ATC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:THIESSE
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 LAKESHORE DR
Mailing Address - Street 2:APT 344
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2382
Mailing Address - Country:US
Mailing Address - Phone:517-990-5490
Mailing Address - Fax:
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 140
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-556-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010016312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer