Provider Demographics
NPI:1912383969
Name:DVORAK, TIA (MS LMFT)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:DVORAK
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18336 JOPLIN ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1773
Mailing Address - Country:US
Mailing Address - Phone:763-350-9687
Mailing Address - Fax:651-447-5394
Practice Address - Street 1:18336 JOPLIN ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1773
Practice Address - Country:US
Practice Address - Phone:763-350-9687
Practice Address - Fax:651-447-5394
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2822106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2822Medicaid