Basic Information
| Provider Information | |||||||||
| NPI: | 1548285695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIESEN | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 SE LAKE RD STE 325 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972222185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037861711 | ||||||||
| FaxNumber: | 5037869919 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 SE LAKE RD STE 325 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972222185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037861711 | ||||||||
| FaxNumber: | 5037869919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1676 | OR | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.