Provider Demographics
NPI:1417526641
Name:NOVOTNAK, TANYA MARIE (PHD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:NOVOTNAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 HAYES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7364
Mailing Address - Country:US
Mailing Address - Phone:608-242-7160
Mailing Address - Fax:
Practice Address - Street 1:4785 HAYES RD STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-7364
Practice Address - Country:US
Practice Address - Phone:608-242-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5192103TC0700X
WI857723103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool