MEDICARE: TA-TANISHA HAWKINS LICSW, MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	31378	MN
2	104100000X	Social Worker	LG50083141	DC
3	1041C0700X	Clinical Social Worker	LC200001893	DC

General Provider Information

NPI Number	:	1760056881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TA-TANISHA HAWKINS LICSW, MSW

Provider Business Mailing Address
First Line	:	716 COUNTY ROAD 10 NE # 232
Second Line	:
City	:	BLAINE
State	:	MN
Zip	:	55434-2331
Country	:	US
Telephone Number	:	202-839-6144
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 CHICAGO AVE STE 200
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2592
Country	:	US
Telephone Number	:	612-596-9438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2021
Last Update Date	:	11/22/2024

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