Healthcare Provider Details

I. General information

NPI: 1124606868
Provider Name (Legal Business Name): TASHENA BRONSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 19TH ST NE
WATERTOWN SD
57201-2823
US

IV. Provider business mailing address

PO BOX 1030
WATERTOWN SD
57201-6030
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-0123
  • Fax: 605-886-5447
Mailing address:
  • Phone: 605-886-0123
  • Fax: 605-886-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number125442
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6287
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: