Provider Demographics
NPI:1245922095
Name:EPHPHATHA TINY MOUTH THERAPY LLC
Entity type:Organization
Organization Name:EPHPHATHA TINY MOUTH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:262-483-6597
Mailing Address - Street 1:9565 BOLTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-9730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490 W ROLLING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-8624
Practice Address - Country:US
Practice Address - Phone:262-483-6597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center