Basic Information
| Provider Information | |||||||||
| NPI: | 1376559716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIESSE | ||||||||
| FirstName: | GLYNIS | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MS LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 617 OAK ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188297140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 617 OAK ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188297140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 4630 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6281371 | 01 | MN | MEDICA | OTHER | 62G75TH | 01 | MN | BCBS | OTHER | 848980 | 01 | MN | ARAZ | OTHER | 115826 | 01 | MN | 115826 | OTHER |