Healthcare Provider Details

I. General information

NPI: 1891062345
Provider Name (Legal Business Name): TARA LIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CHICAGO AVE
MINNEAPOLIS MN
55404
US

IV. Provider business mailing address

4075 275TH ST W
NORTHFIELD MN
55057
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-8513
  • Fax:
Mailing address:
  • Phone: 952-240-4253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19617
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: