Provider Demographics
NPI:1225026404
Name:WILLIHNGANZ, MELODIE S (MS CLL A)
Entity Type:Individual
Prefix:
First Name:MELODIE
Middle Name:S
Last Name:WILLIHNGANZ
Suffix:
Gender:F
Credentials:MS CLL A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1131
Mailing Address - Country:US
Mailing Address - Phone:920-887-0407
Mailing Address - Fax:
Practice Address - Street 1:130 WARREN ST
Practice Address - Street 2:SUITE 211
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3062
Practice Address - Country:US
Practice Address - Phone:920-887-0509
Practice Address - Fax:920-887-0518
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI238156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41129200Medicaid
WI41129200Medicaid