Provider Demographics
NPI:1992991756
Name:IVERSON, KATIE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:IVERSON
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 1:1008 LANDFRIED AVE
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-1525
Mailing Address - Country:US
Mailing Address - Phone:715-821-9220
Mailing Address - Fax:
Practice Address - Street 1:702 W DOLF ST
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421-9604
Practice Address - Country:US
Practice Address - Phone:715-223-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3016-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992991756Medicaid