Provider Demographics
NPI:1154814564
Name:TAZELAAR-WILLIAMS, LAURIE K
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:K
Last Name:TAZELAAR-WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10818
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-0818
Mailing Address - Country:US
Mailing Address - Phone:612-380-3333
Mailing Address - Fax:
Practice Address - Street 1:5253 W BALD EAGLE BLVD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6532
Practice Address - Country:US
Practice Address - Phone:612-380-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities