Healthcare Provider Details

I. General information

NPI: 1447951793
Provider Name (Legal Business Name): TANDRA OKANU MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AMERICAN BLVD E
BLOOMINGTON MN
55425-1232
US

IV. Provider business mailing address

6867 AVENA PATH
INVER GROVE HEIGHTS MN
55077-6800
US

V. Phone/Fax

Practice location:
  • Phone: 763-954-1450
  • Fax:
Mailing address:
  • Phone: 763-954-1450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4248
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: