1336418730 NPI number — TANAGER YVONNE POLOWCHAK MA, LPCC

Table of content: TANAGER YVONNE POLOWCHAK MA, LPCC (NPI 1336418730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336418730 NPI number — TANAGER YVONNE POLOWCHAK MA, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLOWCHAK
Provider First Name:
TANAGER
Provider Middle Name:
YVONNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPCC
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:
1336418730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD NW STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-1789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-628-9566
Provider Business Mailing Address Fax Number:
651-628-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10729 TOWN SQUARE DR NE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55449-7923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-343-9010
Provider Business Practice Location Address Fax Number:
763-343-9011
Provider Enumeration Date:
12/14/2011

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: 101YM0800X , with the licence number:  LPCC2804 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 2804 , 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)





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