Basic Information
| Provider Information | |||||||||
| NPI: | 1598977613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.S.CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | N164W20505 CURRANT LN | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530378987 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1119 N WISCONSIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622845892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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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 | 235Z00000X | 2872-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 42581700 | 05 | WI | MEDICAID |