MEDICARE: TAMARA LYNN ALTHOFF MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7189	MN
2	235Z00000X	Speech-Language Pathologist	2386-154	WI

General Provider Information

NPI Number	:	1194939975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA LYNN ALTHOFF MS CCC-SLP

Provider Business Mailing Address
First Line	:	2832 230TH AVE
Second Line	:
City	:	CLEAR LAKE
State	:	WI
Zip	:	54005-4415
Country	:	US
Telephone Number	:	715-263-3307
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 E 14TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-1314
Country	:	US
Telephone Number	:	612-238-5425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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