Basic Information
Provider Information | |||||||||
NPI: | 1548603830 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WITTE | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | O'CONNOR | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 W MAIN ST | ||||||||
Address2: | SUITE 200 GOODHUE HALL | ||||||||
City: | WHITEWATER | ||||||||
State: | WI | ||||||||
PostalCode: | 531901705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148409754 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 709 MEADOW PARK DR | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | WI | ||||||||
PostalCode: | 535259777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6086762202 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2013 | ||||||||
LastUpdateDate: | 04/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3729-154 | WI | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.