Provider Demographics
NPI:1053474411
Name:MADLER, TAMARA MARIE (LCSW, LAC, LICSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:MARIE
Last Name:MADLER
Suffix:
Gender:F
Credentials:LCSW, LAC, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 PAGE DR S STE 201
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3536
Mailing Address - Country:US
Mailing Address - Phone:701-203-9013
Mailing Address - Fax:855-938-8229
Practice Address - Street 1:1351 PAGE DR S STE 201
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3536
Practice Address - Country:US
Practice Address - Phone:701-203-9013
Practice Address - Fax:855-938-2249
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3137101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19151Medicaid
MN893674100Medicaid