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NPI Code Detail

MEDICARE: MAUREEN TANIS LICSW

MEDICARE: MAUREEN TANIS LICSW
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
11041C0700XClinical Social Worker8690MN

General Provider Information

NPI Number : 1881678928
Entity Type Code : Individual
Provider Name (Legal Business Name) : MAUREEN TANIS LICSW
Provider Business Mailing Address
First Line : 8170 33RD AVE S # MS 21110Q
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55425-4516
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1415 SAINT FRANCIS AVE
Second Line :
City : SHAKOPEE
State : MN
Zip : 55379-3374
Country : US
Telephone Number : 952-993-7750
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/02/2005
Last Update Date : 03/17/2018

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