1518453554 NPI number — TABBATHA JO LITCHKE HERDMAN MS ED, LPCC

Table of content: TABBATHA JO LITCHKE HERDMAN MS ED, LPCC (NPI 1518453554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518453554 NPI number — TABBATHA JO LITCHKE HERDMAN MS ED, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LITCHKE HERDMAN
Provider First Name:
TABBATHA
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS ED, LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LITCHKE
Provider Other First Name:
TABBATHA
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS ED, LPCC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1518453554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 NW 1ST AVE STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55744-2749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 NW 1ST AVE STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-392-5904
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2018

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: 101YP2500X , with the licence number:  1849 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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