Provider Demographics
NPI:1174075261
Name:WYSE, TARA SUZANNE (SLP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:SUZANNE
Last Name:WYSE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:SUZANNE
Other - Last Name:PIGUET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2244 E SHAWNEE BYP
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1446
Mailing Address - Country:US
Mailing Address - Phone:918-684-9999
Mailing Address - Fax:888-663-4223
Practice Address - Street 1:2244 E SHAWNEE BYP
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1446
Practice Address - Country:US
Practice Address - Phone:918-684-9999
Practice Address - Fax:888-663-4223
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4877235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200823950AMedicaid