1578861498 NPI number — MRS. TRACY CHARISSE LARSON M.A

Table of content: MRS. TRACY CHARISSE LARSON M.A (NPI 1578861498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578861498 NPI number — MRS. TRACY CHARISSE LARSON M.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
TRACY
Provider Middle Name:
CHARISSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578861498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13251
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54843-3251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-634-0607
Provider Business Mailing Address Fax Number:
715-634-0617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15655 COUNTY RD B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYWARD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54843-3251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-634-0607
Provider Business Practice Location Address Fax Number:
715-634-0617
Provider Enumeration Date:
03/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 751 - 226 . This is a "PROFESSIONAL COUNSELOR TRAINING LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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