Provider Demographics
NPI:1346914447
Name:DETLOFF, TAMARA KAY
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:KAY
Last Name:DETLOFF
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 452
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-0452
Mailing Address - Country:US
Mailing Address - Phone:218-346-2322
Mailing Address - Fax:
Practice Address - Street 1:316 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1508
Practice Address - Country:US
Practice Address - Phone:218-346-2322
Practice Address - Fax:218-346-2323
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician