Basic Information
| Provider Information | |||||||||
| NPI: | 1871906891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITTROCK | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCC/SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DETTLE | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7581 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517484338 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4570 COUNTY ROAD 61 | ||||||||
| Address2: | |||||||||
| City: | MOOSE LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557679401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184852020 | ||||||||
| FaxNumber: | 2184852044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 9592 | MN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.