Healthcare Provider Details

I. General information

NPI: 1174075261
Provider Name (Legal Business Name): TARA SUZANNE WYSE SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA SUZANNE PIGUET SLP

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 E SHAWNEE BYP
MUSKOGEE OK
74403-1446
US

IV. Provider business mailing address

2244 E SHAWNEE BYP
MUSKOGEE OK
74403-1446
US

V. Phone/Fax

Practice location:
  • Phone: 918-684-9999
  • Fax: 888-663-4223
Mailing address:
  • Phone: 918-684-9999
  • Fax: 888-663-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4877
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: