Provider Demographics
NPI:1568405512
Name:THOMALLA, GISELLE L (PH,D)
Entity Type:Individual
Prefix:DR
First Name:GISELLE
Middle Name:L
Last Name:THOMALLA
Suffix:
Gender:F
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 615
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0615
Mailing Address - Country:US
Mailing Address - Phone:219-476-0042
Mailing Address - Fax:
Practice Address - Street 1:4004 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-1773
Practice Address - Country:US
Practice Address - Phone:219-476-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040596A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN160730Medicare ID - Type UnspecifiedPSYCHOLOGIST