Provider Demographics
NPI:1265890743
Name:THRALL, TISHA LYNN (MS, LPC)
Entity type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:LYNN
Last Name:THRALL
Suffix:
Gender:F
Credentials:MS, LPC
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 30
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-0030
Mailing Address - Country:US
Mailing Address - Phone:660-359-4487
Mailing Address - Fax:
Practice Address - Street 1:29043 IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-2225
Practice Address - Country:US
Practice Address - Phone:816-261-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010041595101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490080878Medicaid