Provider Demographics
NPI:1962697722
Name:MATULLE, TERRY VERNON (MS, CCC-A)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:VERNON
Last Name:MATULLE
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S MAIN ST STE 14
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-3959
Mailing Address - Country:US
Mailing Address - Phone:608-752-3529
Mailing Address - Fax:608-752-3529
Practice Address - Street 1:20 S MAIN ST STE 14
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3959
Practice Address - Country:US
Practice Address - Phone:608-752-3529
Practice Address - Fax:608-752-3529
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI189156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41110400Medicaid