Healthcare Provider Details

I. General information

NPI: 1962986612
Provider Name (Legal Business Name): TARA BETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AMERICAN BLVD E
BLOOMINGTON MN
55425-1232
US

IV. Provider business mailing address

1801 AMERICAN BLVD E
BLOOMINGTON MN
55425-1232
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-2267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: