Basic Information
Provider Information | |||||||||
NPI: | 1225275035 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLECK | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2711 S ROUSE ST STE C&D | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667626620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202311068 | ||||||||
FaxNumber: | 6202312792 | ||||||||
Practice Location | |||||||||
Address1: | 2711 S ROUSE ST STE C&D | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667626620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202311068 | ||||||||
FaxNumber: | 6202312792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2009 | ||||||||
LastUpdateDate: | 06/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1242 | KS | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 1303 | KS | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.