Provider Demographics
NPI:1912252198
Name:COMBS, TARRA ANNE
Entity Type:Individual
Prefix:
First Name:TARRA
Middle Name:ANNE
Last Name:COMBS
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 1:700 N WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-6947
Mailing Address - Country:US
Mailing Address - Phone:920-456-2030
Mailing Address - Fax:
Practice Address - Street 1:700 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-6947
Practice Address - Country:US
Practice Address - Phone:920-456-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3685-57103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100093331Medicaid