Basic Information
| Provider Information | |||||||||
| NPI: | 1659516722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAVEL | ||||||||
| FirstName: | TASHA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.A. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3117 SHORE DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157325111 | ||||||||
| FaxNumber: | 7157320628 | ||||||||
| Practice Location | |||||||||
| Address1: | 3117 SHORE DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157325111 | ||||||||
| FaxNumber: | 7157320628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2008 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3129-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 3129-154 | 01 | WI | WISCONSIN STATE LICENSE | OTHER |