Provider Demographics
NPI:1982774352
Name:THINESEN, PAUL JOHN (MA LP BCBA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:THINESEN
Suffix:
Gender:M
Credentials:MA LP BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 MORNINGSIDE RD
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9109
Mailing Address - Country:US
Mailing Address - Phone:651-263-0763
Mailing Address - Fax:
Practice Address - Street 1:2565 MORNINGSIDE RD
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-9109
Practice Address - Country:US
Practice Address - Phone:651-263-0763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0762103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6190806OtherMEDICA
MN84G16THOtherBCBS
MN191308OtherVALUEOPTIONS ID
MN232850000Medicaid