Provider Demographics
NPI:1164004016
Name:TAWWATER, BRYNN ROSE, THERESE (RBT)
Entity Type:Individual
Prefix:MRS
First Name:BRYNN
Middle Name:ROSE, THERESE
Last Name:TAWWATER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 OLD SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3305
Mailing Address - Country:US
Mailing Address - Phone:262-262-6715
Mailing Address - Fax:
Practice Address - Street 1:7110 OLD SPRING ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3305
Practice Address - Country:US
Practice Address - Phone:262-262-6715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100054228Medicaid