Provider Demographics
NPI:1871906891
Name:WITTROCK, TARA (CCC/SLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WITTROCK
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:DETTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1939 MINNEHAHA AVE W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1033
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:4791 COUNTY ROAD 10 STE 102
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9221
Practice Address - Country:US
Practice Address - Phone:218-485-2020
Practice Address - Fax:218-485-2044
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist