Provider Demographics
NPI:1255526455
Name:MALVITZ, TASHA JOY (MA/CCC-SLP)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:JOY
Last Name:MALVITZ
Suffix:
Gender:F
Credentials:MA/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 DOUSMAN STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-2770
Mailing Address - Country:US
Mailing Address - Phone:920-593-4382
Mailing Address - Fax:
Practice Address - Street 1:1673 DOUSMAN STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54307-2770
Practice Address - Country:US
Practice Address - Phone:920-593-4382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2613-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist