Provider Demographics
NPI:1679821045
Name:TAN, ANNETTE W (SLP)
Entity type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:W
Last Name:TAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 W VLIET ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-2453
Mailing Address - Country:US
Mailing Address - Phone:414-231-4085
Mailing Address - Fax:414-231-4014
Practice Address - Street 1:3220 W VLIET ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-2453
Practice Address - Country:US
Practice Address - Phone:414-231-4085
Practice Address - Fax:414-231-4014
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3384-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist