Provider Demographics
NPI:1164224226
Name:DAWSON, TEQUILLA (MHA)
Entity type:Individual
Prefix:
First Name:TEQUILLA
Middle Name:
Last Name:DAWSON
Suffix:
Gender:F
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E ENTERPRISE AVE STE 333
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7889
Mailing Address - Country:US
Mailing Address - Phone:608-218-1169
Mailing Address - Fax:
Practice Address - Street 1:2800 E ENTERPRISE AVE STE 333
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7889
Practice Address - Country:US
Practice Address - Phone:608-218-1169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 374U00000X, 385H00000X, 305S00000X
WI253Z00000X405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care
No405300000XOther Service ProvidersPrevention Professional
No305S00000XManaged Care OrganizationsPoint of Service