Provider Demographics
NPI:1811276819
Name:DOMAZET, TAMARA (LICSW)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:DOMAZET
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 RIVER WOODS LN
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-3322
Mailing Address - Country:US
Mailing Address - Phone:507-334-1983
Mailing Address - Fax:507-333-2307
Practice Address - Street 1:152 RIVER WOODS LN
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-3322
Practice Address - Country:US
Practice Address - Phone:507-334-1983
Practice Address - Fax:507-333-2307
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN195641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19564OtherSTATE OF MINNESOTA BOARD OF SOCIAL WORK