Provider Demographics
NPI:1922587344
Name:HOMOLKA, TERAH
Entity Type:Individual
Prefix:
First Name:TERAH
Middle Name:
Last Name:HOMOLKA
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 1:1405 HERITAGE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3396
Mailing Address - Country:US
Mailing Address - Phone:715-571-5056
Mailing Address - Fax:
Practice Address - Street 1:1436 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3427
Practice Address - Country:US
Practice Address - Phone:715-526-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10112235Z00000X
WI5095-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist