Provider Demographics
NPI:1366959967
Name:TISCHER THERAPEUTIC SERVICES SUBSTANCE ABUSE TREATMENT PROGRAM
Entity type:Organization
Organization Name:TISCHER THERAPEUTIC SERVICES SUBSTANCE ABUSE TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONYA
Authorized Official - Middle Name:BERTEEN
Authorized Official - Last Name:BLAIR-TISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PSYD, LPCC, LP
Authorized Official - Phone:218-651-0212
Mailing Address - Street 1:115 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1434
Mailing Address - Country:US
Mailing Address - Phone:218-651-0212
Mailing Address - Fax:218-651-0220
Practice Address - Street 1:115 5TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1434
Practice Address - Country:US
Practice Address - Phone:218-651-0212
Practice Address - Fax:218-651-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1090064261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder