Provider Demographics
NPI:1487620837
Name:SPEECH THERAPY ASSOCIATES OF NORTHWEST WISCONSIN, LTD
Entity type:Organization
Organization Name:SPEECH THERAPY ASSOCIATES OF NORTHWEST WISCONSIN, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUNDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MAT/CCC/SLP
Authorized Official - Phone:715-859-6670
Mailing Address - Street 1:2523 14 3/4 AVE
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-8736
Mailing Address - Country:US
Mailing Address - Phone:715-859-6670
Mailing Address - Fax:715-859-6669
Practice Address - Street 1:900 COLLEGE AVE W
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-2116
Practice Address - Country:US
Practice Address - Phone:715-532-5561
Practice Address - Fax:715-532-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1112-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42551300Medicaid