Basic Information
Provider Information | |||||||||
NPI: | 1811016918 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RETTKE | ||||||||
FirstName: | TRISHA | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TENHOUSE | ||||||||
OtherFirstName: | TRISHA | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1025 MAINE ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | IL | ||||||||
PostalCode: | 623014096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172226550 | ||||||||
FaxNumber: | 2172772253 | ||||||||
Practice Location | |||||||||
Address1: | 1025 MAINE ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | IL | ||||||||
PostalCode: | 62301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172226550 | ||||||||
FaxNumber: | 2172772253 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2007 | ||||||||
LastUpdateDate: | 07/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146-008273 | IL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.