Provider Demographics
NPI:1063705929
Name:THIRY, MARIANNE BERNADETTE (LADC)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:BERNADETTE
Last Name:THIRY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37626 RENDOVA ST NE
Mailing Address - Street 2:
Mailing Address - City:STANCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55080-5025
Mailing Address - Country:US
Mailing Address - Phone:320-396-3528
Mailing Address - Fax:
Practice Address - Street 1:17305 MEADOW CREEK LANE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063
Practice Address - Country:US
Practice Address - Phone:763-444-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301772101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)