Healthcare Provider Details

I. General information

NPI: 1821951674
Provider Name (Legal Business Name): TARA FITZGERALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 BIRCH ST
LINO LAKES MN
55014-1369
US

IV. Provider business mailing address

3114 ARTHUR ST NE
MINNEAPOLIS MN
55418-2211
US

V. Phone/Fax

Practice location:
  • Phone: 763-792-6144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1005279
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: