Provider Demographics
NPI:1851623326
Name:THIESSEN, CHONNIE SUTTON
Entity Type:Individual
Prefix:
First Name:CHONNIE
Middle Name:SUTTON
Last Name:THIESSEN
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:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92235-0323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74967 SHERYL AVE STE 7
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2073
Practice Address - Country:US
Practice Address - Phone:760-283-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120392101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health