Basic Information
| Provider Information | |||||||||
| NPI: | 1053910091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLTER | ||||||||
| FirstName: | CASEY | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6551 WENDELL CT | ||||||||
| Address2: | |||||||||
| City: | DEFOREST | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535322778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082350594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662934 | ||||||||
| FaxNumber: | 4142666189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 725-156 | WI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1609232933 | 05 | WI | MEDICAID |