Provider Demographics
NPI:1720587272
Name:THAU, ALYSSA SARAH LYNN
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:SARAH LYNN
Last Name:THAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 DIAMOND LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-6080
Mailing Address - Country:US
Mailing Address - Phone:406-560-3357
Mailing Address - Fax:
Practice Address - Street 1:112 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5011
Practice Address - Country:US
Practice Address - Phone:208-465-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9650101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health