Provider Demographics
NPI:1205338969
Name:PROM, TARA M (LICSW)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:M
Last Name:PROM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:SCHLOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1114 SOMERSET BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-0750
Mailing Address - Country:US
Mailing Address - Phone:320-266-0241
Mailing Address - Fax:
Practice Address - Street 1:22 WILSON AVE NE SUITE 110
Practice Address - Street 2:PO BOX 6069
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56302-6069
Practice Address - Country:US
Practice Address - Phone:320-251-7700
Practice Address - Fax:320-251-8898
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN173381041C0700X
MN429597101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool