Provider Demographics
NPI:1194320473
Name:MORALES, TAMARA JEAN (LADC)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:JEAN
Last Name:MORALES
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17641 COUNTY ROAD 66 NE
Mailing Address - Street 2:
Mailing Address - City:MILTONA
Mailing Address - State:MN
Mailing Address - Zip Code:56354-8272
Mailing Address - Country:US
Mailing Address - Phone:763-260-3347
Mailing Address - Fax:
Practice Address - Street 1:310 US 71 N
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378-4919
Practice Address - Country:US
Practice Address - Phone:320-272-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305212101YA0400X
MN1106471101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)