Provider Demographics
NPI:1003857863
Name:GLASER, KIM ANN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:ANN
Last Name:GLASER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11726 N COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2939
Mailing Address - Country:US
Mailing Address - Phone:262-512-0821
Mailing Address - Fax:
Practice Address - Street 1:13111 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2416
Practice Address - Country:US
Practice Address - Phone:262-243-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1810-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist