Basic Information
| Provider Information | |||||||||
| NPI: | 1932627692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUERNBERG | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WENZEL | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17700 W CAPITOL DR | ||||||||
| Address2: | LESSILA THERAPY | ||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627813083 | ||||||||
| FaxNumber: | 2627813080 | ||||||||
| Practice Location | |||||||||
| Address1: | 198 COUNTY ROAD DF | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863548 | ||||||||
| FaxNumber: | 9202393997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 14052695 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 14052695 | 01 | WI | LICENSE NUMBER | OTHER |