Provider Demographics
NPI:1003026121
Name:LOESCH, KELLY JO (MT-BC, WMTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:LOESCH
Suffix:
Gender:F
Credentials:MT-BC, WMTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W156N10531 JEFFERSON LN
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4123
Mailing Address - Country:US
Mailing Address - Phone:414-651-4432
Mailing Address - Fax:
Practice Address - Street 1:1125 JAMES DR
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-8310
Practice Address - Country:US
Practice Address - Phone:262-367-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82-38225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist