Provider Demographics
NPI:1558995746
Name:THORSON, MARLYSSA (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:MARLYSSA
Middle Name:
Last Name:THORSON
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4818 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1306
Mailing Address - Country:US
Mailing Address - Phone:952-836-6789
Mailing Address - Fax:
Practice Address - Street 1:7260 UNIVERSITY AVE NE STE 235
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3141
Practice Address - Country:US
Practice Address - Phone:763-572-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2372101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional