Provider Demographics
NPI:1629351473
Name:DUQUAINE, TARA ANN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:DUQUAINE
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 1:2609 N PROSPECT AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3727
Mailing Address - Country:US
Mailing Address - Phone:920-471-7065
Mailing Address - Fax:
Practice Address - Street 1:2609 N PROSPECT AVE APT 3
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-3727
Practice Address - Country:US
Practice Address - Phone:920-471-7065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3614-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist