Provider Demographics
NPI:1386069524
Name:ELIE, TARA BETHANY
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:BETHANY
Last Name:ELIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BETHANY
Other - Last Name:CALDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11141 ZEALAND AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3595
Mailing Address - Country:US
Mailing Address - Phone:763-951-3091
Mailing Address - Fax:763-951-3097
Practice Address - Street 1:411 3RD ST SE
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:MN
Practice Address - Zip Code:55369-1606
Practice Address - Country:US
Practice Address - Phone:763-951-3091
Practice Address - Fax:763-951-3097
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4210106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist