Provider Demographics
NPI:1518453554
Name:LITCHKE HERDMAN, TABBATHA JO (MS ED, LPCC)
Entity Type:Individual
Prefix:
First Name:TABBATHA
Middle Name:JO
Last Name:LITCHKE HERDMAN
Suffix:
Gender:F
Credentials:MS ED, LPCC
Other - Prefix:
Other - First Name:TABBATHA
Other - Middle Name:JO
Other - Last Name:LITCHKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS ED, LPCC
Mailing Address - Street 1:204 NW 1ST AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 NW 1ST AVE STE 4
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2749
Practice Address - Country:US
Practice Address - Phone:218-392-5904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional