Provider Demographics
NPI:1700430832
Name:TIZA, SARITA CONSUELO (LICSW)
Entity Type:Individual
Prefix:
First Name:SARITA
Middle Name:CONSUELO
Last Name:TIZA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SARITA
Other - Middle Name:CONSUELO
Other - Last Name:ENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1602 8TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-1504
Mailing Address - Country:US
Mailing Address - Phone:507-676-2979
Mailing Address - Fax:
Practice Address - Street 1:400 E 1ST ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1408
Practice Address - Country:US
Practice Address - Phone:507-451-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN258821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical