Healthcare Provider Details

I. General information

NPI: 1164230074
Provider Name (Legal Business Name): TAYA VACANTI MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 WAYZATA BLVD STE 510
ST LOUIS PARK MN
55416-1340
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 952-254-3557
  • Fax:
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number30707
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: