Provider Demographics
NPI:1316079650
Name:THANDER, ELAINE (MA,LP)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:
Last Name:THANDER
Suffix:
Gender:F
Credentials:MA,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 UPTON AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1931
Mailing Address - Country:US
Mailing Address - Phone:612-874-1300
Mailing Address - Fax:612-836-1722
Practice Address - Street 1:2736 LYNDALE AVE S
Practice Address - Street 2:#208
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1309
Practice Address - Country:US
Practice Address - Phone:612-874-1300
Practice Address - Fax:612-835-1722
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist