Provider Demographics
NPI:1689267700
Name:DELA ROSA, TARA JOY
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JOY
Last Name:DELA ROSA
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 1:2405 8TH ST S STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4200
Mailing Address - Country:US
Mailing Address - Phone:218-331-4866
Mailing Address - Fax:218-331-4867
Practice Address - Street 1:2405 8TH ST S STE 200
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4200
Practice Address - Country:US
Practice Address - Phone:218-331-4866
Practice Address - Fax:218-331-4867
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2735101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor