Provider Demographics
NPI:1285462796
Name:FOYTIK, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FOYTIK
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 1:3211 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6852
Mailing Address - Country:US
Mailing Address - Phone:920-242-9582
Mailing Address - Fax:
Practice Address - Street 1:926 WILLARD DR STE 136
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5296
Practice Address - Country:US
Practice Address - Phone:920-659-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1118-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist