Provider Demographics
NPI:1326417890
Name:VANCE, TAMARA (LICSW)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WILLSON RD STE 440
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1332
Mailing Address - Country:US
Mailing Address - Phone:763-270-0054
Mailing Address - Fax:763-208-6371
Practice Address - Street 1:5200 WILLSON RD STE 440
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1332
Practice Address - Country:US
Practice Address - Phone:763-270-0054
Practice Address - Fax:763-208-6371
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical