1134348949 NPI number — MRS. TAMARA B CHRISTENSON LICSW

Table of content: MRS. TAMARA B CHRISTENSON LICSW (NPI 1134348949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134348949 NPI number — MRS. TAMARA B CHRISTENSON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTENSON
Provider First Name:
TAMARA
Provider Middle Name:
B
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134348949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5476 MUD LAKE LN SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56308-6304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-763-9612
Provider Business Mailing Address Fax Number:
320-762-0796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 BROADWAY ST STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56308-1482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-762-1762
Provider Business Practice Location Address Fax Number:
320-762-0796
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  13897 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 524G3CH . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 31002005 . This is a "PRIME WEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 652620900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56308-A003 . This is a "TRIWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 138661 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 990991049165 . This is a "BHP PREFERRED 1" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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