Provider Demographics
NPI:1770532558
Name:WILGENBUSCH, TAMMY LYNN (PHD)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:WILGENBUSCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:VINZANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-7999
Mailing Address - Fax:319-384-7899
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-7999
Practice Address - Fax:319-384-7899
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000463103T00000X
IA000984103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06072OtherWELLMARK BC BS
Q61211Medicare UPIN
IAI16787Medicare PIN