Provider Demographics
NPI:1659871812
Name:TASSOUL, TAYLOR LEIGH (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEIGH
Last Name:TASSOUL
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5969 VALLEY HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54141-8661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 FOREST GROVE DR STE 207
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3738
Practice Address - Country:US
Practice Address - Phone:877-732-2262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1886-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer