Provider Demographics
NPI:1578861498
Name:LARSON, TRACY CHARISSE (MA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:CHARISSE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13251
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-3251
Mailing Address - Country:US
Mailing Address - Phone:715-634-0607
Mailing Address - Fax:715-634-0617
Practice Address - Street 1:15655 COUNTY RD B
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3251
Practice Address - Country:US
Practice Address - Phone:715-634-0607
Practice Address - Fax:715-634-0617
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI751 - 226OtherPROFESSIONAL COUNSELOR TRAINING LICENSE