Provider Demographics
NPI:1285656389
Name:NOGOWSKI, TARA L
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:NOGOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GWINNER
Mailing Address - State:ND
Mailing Address - Zip Code:58040-0586
Mailing Address - Country:US
Mailing Address - Phone:701-678-2244
Mailing Address - Fax:701-678-2210
Practice Address - Street 1:11 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:GWINNER
Practice Address - State:ND
Practice Address - Zip Code:58040-0586
Practice Address - Country:US
Practice Address - Phone:701-678-2244
Practice Address - Fax:701-678-2210
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND911235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51065Medicaid