Basic Information
| Provider Information | |||||||||
| NPI: | 1265801740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TASSARA | ||||||||
| FirstName: | MARCEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 S HATELY AVE | ||||||||
| Address2: | |||||||||
| City: | CUDAHY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531102041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148019596 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1032 S CESAR E CHAVEZ DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
| FaxNumber: | 4146724265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3332 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.