Provider Demographics
NPI:1982648341
Name:TAZELAAR, SANDRA LEE (LICSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:TAZELAAR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEE
Other - Last Name:STARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1595 SELBY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6221
Mailing Address - Country:US
Mailing Address - Phone:651-699-6480
Mailing Address - Fax:651-699-4889
Practice Address - Street 1:1595 SELBY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-699-6480
Practice Address - Fax:651-699-4889
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN94541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical