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General NPI Number Information
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NPI Number | 1386069524
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Entity Type | Individual
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Provider Name | TARA BETHANY ELIE
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Gender | Female
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Dates
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Enumeration Date | 02/25/2014
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Last Update Date | 03/28/2024
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Provider Practice Location Address
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Address Line | 411 3RD ST SE
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City | OSSEO
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State | MN
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Zip | 55369-1606
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Country | US
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Telephone | 763-951-3091
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Fax | 763-951-3097
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Provider Business Mailing Address
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Address Line | 11141 ZEALAND AVE N
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City | CHAMPLIN
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State | MN
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Zip | 55316-3595
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Country | US
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Telephone | 763-951-3091
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Fax | 763-951-3097
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4210
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License Number State | MN
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