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General NPI Number Information
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NPI Number | 1518346261
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Entity Type | Organization
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Legal Business Name | HEALTHY MINDS OF THE FOX VALLEY LLC
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Dates
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Enumeration Date | 05/28/2015
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Last Update Date | 06/10/2015
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Provider Practice Location Address
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Address Line | 1045 N LYNNDALE DR STE 1C
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City | APPLETON
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State | WI
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Zip | 54914-3048
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Country | US
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Telephone | 902-551-0013
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Fax |
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Provider Business Mailing Address
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Address Line | 6188 CLARKS RD
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City | WINNECONNE
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State | WI
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Zip | 54986-9760
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Country | US
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Telephone | 908-551-0013
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TAMMY LEE HIETPAS
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Credential | PHD
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Telephone | 715-937-8819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 72200-1519
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License Number State | WI
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