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General NPI Number Information
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NPI Number | 1811286594
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Entity Type | Organization
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Legal Business Name | TAZELAAR PSYCHOTHERAPY SERVICES LLC
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Dates
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Enumeration Date | 04/01/2011
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Last Update Date | 03/25/2015
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Provider Practice Location Address
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Address Line | 1595 SELBY AVE
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City | SAINT PAUL
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State | MN
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Zip | 55104-6221
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Country | US
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Telephone | 651-699-6480
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Fax | 651-699-4889
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Provider Business Mailing Address
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Address Line | 232 SNELLING AVE S
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City | SAINT PAUL
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State | MN
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Zip | 55105-1944
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Country | US
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Telephone | 651-699-6480
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Fax | 651-699-4889
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Authorized Official
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Title or Position | OWNER
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Name | MS. SANDRA LEE TAZELAAR
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Credential | LICSW
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Telephone | 651-699-6480
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 9454
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License Number State | MN
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