Healthcare Provider Details

I. General information

NPI: 1588181408
Provider Name (Legal Business Name): TRISTAN HARTER NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 WINSTON DR
BOLINGBROOK IL
60440-1300
US

IV. Provider business mailing address

WOOD VIEW ELEMENTARY SCHOOL 197 WINSTON DR.
BOLINGBROOK IL
60440
US

V. Phone/Fax

Practice location:
  • Phone: 630-739-0185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: