Basic Information
| Provider Information | |||||||||
| NPI: | 1679127534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAYYIL | ||||||||
| FirstName: | TERESA | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1997 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532011997 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE STE B340 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662934 | ||||||||
| FaxNumber: | 4142666189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2019 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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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 | 231H00000X | 701-156 | WI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1306214028 | 05 | WI | MEDICAID |