Provider Demographics
NPI:1780851766
Name:GABRIELSON, TARA ANN (BS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:GABRIELSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 4TH ST
Mailing Address - Street 2:EAST CENTRAL MHICD CENTER INC
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006
Mailing Address - Country:US
Mailing Address - Phone:605-697-2850
Mailing Address - Fax:605-697-2874
Practice Address - Street 1:211 4TH ST
Practice Address - Street 2:EAST CENTRAL MHICD CENTER INC
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006
Practice Address - Country:US
Practice Address - Phone:605-697-2850
Practice Address - Fax:605-697-2874
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5200060Medicaid