Healthcare Provider Details

I. General information

NPI: 1447727425
Provider Name (Legal Business Name): TANYA RAE BEDNAREK MSW, LICSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E 4TH ST
DULUTH MN
55805-2147
US

IV. Provider business mailing address

1401 EAST 1ST STREET
DULUTH MN
55805-2407
US

V. Phone/Fax

Practice location:
  • Phone: 218-728-4491
  • Fax: 218-302-8698
Mailing address:
  • Phone: 218-728-4491
  • Fax: 218-730-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305126
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29306
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: