Provider Demographics
NPI:1124852538
Name:VAN MAANEN, TESSA CORIN
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:CORIN
Last Name:VAN MAANEN
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 1:615 BOYSON RD NE APT 233
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-7391
Mailing Address - Country:US
Mailing Address - Phone:641-891-9648
Mailing Address - Fax:
Practice Address - Street 1:2115 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-6353
Practice Address - Country:US
Practice Address - Phone:319-363-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA127681235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist