Provider Demographics
NPI:1689146102
Name:TALLAKSON, PATRICIA SUE (LPC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:SUE
Last Name:TALLAKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 3RD AVE S STE 303
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1865
Mailing Address - Country:US
Mailing Address - Phone:701-364-4040
Mailing Address - Fax:
Practice Address - Street 1:808 3RD AVE S STE 303
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1865
Practice Address - Country:US
Practice Address - Phone:701-364-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND510-6-15-04101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor