Provider Demographics
NPI:1902133440
Name:FOSSUM, THYRA ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:THYRA
Middle Name:ANNE
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 SNELLING AVENUE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:612-229-8198
Mailing Address - Fax:
Practice Address - Street 1:1595 SELBY AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6221
Practice Address - Country:US
Practice Address - Phone:612-229-8198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4703103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical