Provider Demographics
NPI:1588370258
Name:PRAIRIE CHICKEN, LARRY S
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:PRAIRIE CHICKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-7805
Mailing Address - Country:US
Mailing Address - Phone:605-224-8841
Mailing Address - Fax:
Practice Address - Street 1:1714 ABBEY RD
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-7805
Practice Address - Country:US
Practice Address - Phone:605-224-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9607858101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)