Provider Demographics
NPI:1184837189
Name:WHITCOMB, TASHA R
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:R
Last Name:WHITCOMB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MAPLE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-9284
Mailing Address - Country:US
Mailing Address - Phone:920-370-2094
Mailing Address - Fax:
Practice Address - Street 1:4605 VALDRES SPRINGS CT
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4189
Practice Address - Country:US
Practice Address - Phone:715-393-0419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1351-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36122600Medicaid