Healthcare Provider Details

I. General information

NPI: 1588982938
Provider Name (Legal Business Name): TERESA ANNE MRNIK MS/CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SHARP RD
WATERFORD WI
53185-5214
US

IV. Provider business mailing address

9245 S ORCHARD PARK CIR #2A
OAK CREEK WI
53154-8222
US

V. Phone/Fax

Practice location:
  • Phone: 262-534-7297
  • Fax: 262-534-7257
Mailing address:
  • Phone: 414-839-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3004-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: