Provider Demographics
NPI:1366852972
Name:TAMBA, KOTATEE (LP, LICSW)
Entity type:Individual
Prefix:
First Name:KOTATEE
Middle Name:
Last Name:TAMBA
Suffix:
Gender:M
Credentials:LP, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 977
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-0977
Mailing Address - Country:US
Mailing Address - Phone:507-446-0431
Mailing Address - Fax:
Practice Address - Street 1:2500 2ND ST NE APT 607
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3588
Practice Address - Country:US
Practice Address - Phone:651-497-9483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN213171041C0700X
MNLP7120103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical