Healthcare Provider Details

I. General information

NPI: 1386069524
Provider Name (Legal Business Name): TARA BETHANY ELIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA BETHANY CALDER

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 3RD ST SE
OSSEO MN
55369-1606
US

IV. Provider business mailing address

11141 ZEALAND AVE N
CHAMPLIN MN
55316-3595
US

V. Phone/Fax

Practice location:
  • Phone: 763-951-3091
  • Fax: 763-951-3097
Mailing address:
  • Phone: 763-951-3091
  • Fax: 763-951-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4210
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: