Provider Demographics
NPI:1588181408
Name:HARTER, TRISTAN (NCSP)
Entity Type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:
Last Name:HARTER
Suffix:
Gender:M
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WOOD VIEW ELEMENTARY SCHOOL
Mailing Address - Street 2:197 WINSTON DR.
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:197 WINSTON DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1300
Practice Address - Country:US
Practice Address - Phone:630-739-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool