Provider Demographics
NPI:1407067994
Name:SHIREK, TARA L (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:L
Last Name:SHIREK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4010
Mailing Address - Country:US
Mailing Address - Phone:701-746-8376
Mailing Address - Fax:701-746-9872
Practice Address - Street 1:735 HILL AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237
Practice Address - Country:US
Practice Address - Phone:701-746-8376
Practice Address - Fax:701-746-9872
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2922104100000X, 1041C0700X
29221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1456289Medicaid
NDN721018Medicare PIN