Provider Demographics
NPI:1215418561
Name:DEWITT, TARA J (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:DEWITT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-3057
Mailing Address - Country:US
Mailing Address - Phone:309-343-1151
Mailing Address - Fax:
Practice Address - Street 1:1135 W FREMONT ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2432
Practice Address - Country:US
Practice Address - Phone:309-973-2272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist