Provider Demographics
NPI:1760056881
Name:HAWKINS, TA-TANISHA (LICSW, MSW)
Entity Type:Individual
Prefix:
First Name:TA-TANISHA
Middle Name:
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:LICSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 COUNTY ROAD 10 NE # 232
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2331
Mailing Address - Country:US
Mailing Address - Phone:202-839-6144
Mailing Address - Fax:
Practice Address - Street 1:5601 QUEBEC AVE N APT 103A
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3383
Practice Address - Country:US
Practice Address - Phone:202-839-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083141104100000X
DCLC2000018931041C0700X
MN313781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker