Basic Information
| Provider Information | |||||||||
| NPI: | 1114139409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUFFLER | ||||||||
| FirstName: | KEIRSEN | ||||||||
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| Credential: | MA, CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13205 W CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531513901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627851160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2315 N LAKE DR | ||||||||
| Address2: | SUITE 1005 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142714141 | ||||||||
| FaxNumber: | 4142714343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 283-156 | WI | X | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 283-156 | WI | X | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 4113000 | 05 | WI | MEDICAID |