Healthcare Provider Details

I. General information

NPI: 1386448231
Provider Name (Legal Business Name): TATIANA KOMLEVA PSY.D., LP.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FREEMAN DR
SAINT PETER MN
56082-3504
US

IV. Provider business mailing address

100 FREEMAN DR
SAINT PETER MN
56082-3504
US

V. Phone/Fax

Practice location:
  • Phone: 507-985-2530
  • Fax:
Mailing address:
  • Phone: 507-985-2530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5990
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number5990
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number5990
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number5990
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number5990
License Number StateMN
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5990
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: