Provider Demographics
NPI:1568843795
Name:KIISKILA, WANDA JOAN (MA, CCC- SLP)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:JOAN
Last Name:KIISKILA
Suffix:
Gender:F
Credentials:MA, CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25770 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1220
Mailing Address - Country:US
Mailing Address - Phone:906-281-1788
Mailing Address - Fax:
Practice Address - Street 1:25770 ELM ST
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1220
Practice Address - Country:US
Practice Address - Phone:906-281-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000233235Z00000X
MI01128628235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist