Basic Information
| Provider Information | |||||||||
| NPI: | 1346807393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIEL | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 713 ANDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202293760 | ||||||||
| FaxNumber: | 3202293762 | ||||||||
| Practice Location | |||||||||
| Address1: | 713 ANDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202293760 | ||||||||
| FaxNumber: | 3202293762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2019 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 23736 | MN | N | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 305083 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.