Basic Information
Provider Information | |||||||||
NPI: | 1265706444 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETOSKEY | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS/CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10945 N. PORT WASHINGTON RD. | ||||||||
Address2: | SUITE 211 | ||||||||
City: | MEQUON | ||||||||
State: | WI | ||||||||
PostalCode: | 530920000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622418000 | ||||||||
FaxNumber: | 2622418096 | ||||||||
Practice Location | |||||||||
Address1: | 2900 W. OKLAHOMA AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532150000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146497772 | ||||||||
FaxNumber: | 4146497977 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2012 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 419-154 | WI | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.