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General NPI Number Information
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NPI Number | 1245922095
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Entity Type | Organization
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Legal Business Name | EPHPHATHA TINY MOUTH THERAPY LLC
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Dates
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Enumeration Date | 05/22/2023
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Last Update Date | 05/22/2023
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Provider Practice Location Address
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Address Line | 490 W ROLLING MEADOWS DR
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City | FOND DU LAC
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State | WI
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Zip | 54937-8624
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Country | US
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Telephone | 262-483-6597
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Fax |
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Provider Business Mailing Address
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Address Line | 9565 BOLTONVILLE RD
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City | KEWASKUM
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State | WI
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Zip | 53040-9730
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRIDGET SCHUMAKER
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Credential | CCC-SLP
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Telephone | 262-483-6597
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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