Provider Demographics
NPI:1053814780
Name:HERRMANN, TARA (LSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HERRMANN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5457 HORIZON DR NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1156
Mailing Address - Country:US
Mailing Address - Phone:218-298-0689
Mailing Address - Fax:
Practice Address - Street 1:7601 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1623
Practice Address - Country:US
Practice Address - Phone:612-223-8898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1907101YA0400X
MN306272101YA0400X
ND4536104100000X
171M00000X
MN20695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator