Basic Information
| Provider Information | |||||||||
| NPI: | 1811324502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALD | ||||||||
| FirstName: | TRINA | ||||||||
| MiddleName: | LANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 S HOLMEN DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | HOLMEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546369467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085269965 | ||||||||
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| Practice Location | |||||||||
| Address1: | 198 COUNTY ROAD DF | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863400 | ||||||||
| FaxNumber: | 9203864186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2013 | ||||||||
| LastUpdateDate: | 09/26/2013 | ||||||||
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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 | 3878-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.