Healthcare Provider Details

I. General information

NPI: 1063031557
Provider Name (Legal Business Name): TARESA JANELLE SPADE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12508 HAWK LN
CLINTON MT
59825-9033
US

IV. Provider business mailing address

1522 E SHORE DR
DETROIT LAKES MN
56501-4707
US

V. Phone/Fax

Practice location:
  • Phone: 808-359-4730
  • Fax:
Mailing address:
  • Phone: 808-359-4730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-4493
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31664
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15379
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101117
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61317222
License Number StateWA
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-42656
License Number StateMT
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.026956
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: