Provider Demographics
NPI:1053527309
Name:GIESE, LARRY J (MA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:J
Last Name:GIESE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 LEWIS RD NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-1361
Mailing Address - Country:US
Mailing Address - Phone:701-663-8778
Mailing Address - Fax:
Practice Address - Street 1:3910 LEWIS RD NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-1361
Practice Address - Country:US
Practice Address - Phone:701-663-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4754106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist