Provider Demographics
NPI:1053582767
Name:TRAXLER, MARK S (MA, LP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:TRAXLER
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:56057-1600
Mailing Address - Country:US
Mailing Address - Phone:507-357-8288
Mailing Address - Fax:
Practice Address - Street 1:88 S PARK AVE
Practice Address - Street 2:
Practice Address - City:LE CENTER
Practice Address - State:MN
Practice Address - Zip Code:56057-1600
Practice Address - Country:US
Practice Address - Phone:507-357-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3579103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist