Healthcare Provider Details

I. General information

NPI: 1831459106
Provider Name (Legal Business Name): TARA MCRAE LORENZ LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA C MCRAE LCSW

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 14TH ST W STE 290
WILLISTON ND
58801-4078
US

IV. Provider business mailing address

307 LAKE ST
NEW SALEM ND
58563-4101
US

V. Phone/Fax

Practice location:
  • Phone: 701-334-6242
  • Fax:
Mailing address:
  • Phone: 707-530-5098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW62900
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW5476
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: