Provider Demographics
NPI:1215174800
Name:KLECKNER, ANN M (CCC-SP)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:KLECKNER
Suffix:
Gender:F
Credentials:CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:WI
Mailing Address - Zip Code:53521-9443
Mailing Address - Country:US
Mailing Address - Phone:608-835-8331
Mailing Address - Fax:
Practice Address - Street 1:3502 MAPLE GROVE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-4879
Practice Address - Country:US
Practice Address - Phone:608-442-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42638500Medicaid