Basic Information
| Provider Information | |||||||||
| NPI: | 1710145099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | MCCREA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GROPPE | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | MCCREA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS CCCA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 219672 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641219672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164074200 | ||||||||
| FaxNumber: | 8164072362 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167816066 | ||||||||
| FaxNumber: | 8167920408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 051 | NE | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 2019044094 | MO | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 2019044094 | 01 | MO | MISSOURI LICENSE | OTHER | 10025369400 | 05 | NE | MEDICAID |