Tara Wittrock, CCC/SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

9592 Issued in MN

Practice address

4791 County Road 10 Ste 102
Moose Lake, MN 55767-9221

Phone

(218) 485-2020

Fax

(218) 485-2044

NPI assigned

Jun 6, 2014

Last updated

Aug 14, 2023By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Tara Dettle Former name

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402012800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1691971200000",
    "number": "1871906891",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1939 MINNEHAHA AVE W STE 300",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551041033",
            "telephone_number": "651-748-4338",
            "fax_number": "651-748-2892"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4791 COUNTY ROAD 10 STE 102",
            "city": "MOOSE LAKE",
            "state": "MN",
            "postal_code": "557679221",
            "telephone_number": "218-485-2020",
            "fax_number": "218-485-2044"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "407 E 3rd St",
            "address_purpose": "LOCATION",
            "city": "Duluth",
            "state": "MN",
            "postal_code": "55805",
            "country_code": "US",
            "telephone_number": "218-786-4000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WITTROCK",
        "first_name": "TARA",
        "credential": "CCC/SLP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-06-06",
        "last_updated": "2023-08-14",
        "certification_date": "2023-08-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "MN",
            "license": "9592",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "TARA",
            "last_name": "DETTLE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Speech-Language Pathologist in Moose Lake, MN
• Providers in Moose Lake, MN by specialty
• Speech-Language Pathologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.