Provider Demographics
NPI:1811286594
Name:TAZELAAR PSYCHOTHERAPY SERVICES LLC
Entity type:Organization
Organization Name:TAZELAAR PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TAZELAAR
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-699-6480
Mailing Address - Street 1:232 SNELLING AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1944
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:55104-6221
Practice Address - Country:US
Practice Address - Phone:651-699-6480
Practice Address - Fax:651-699-4889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN94541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty