Provider Demographics
NPI:1225353329
Name:BLAKE-VOGT, PEGGY SUE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:SUE
Last Name:BLAKE-VOGT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK
Mailing Address - State:WI
Mailing Address - Zip Code:54826-9716
Mailing Address - Country:US
Mailing Address - Phone:715-205-1048
Mailing Address - Fax:
Practice Address - Street 1:802 E COUNTY HIGHWAY B
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-4425
Practice Address - Country:US
Practice Address - Phone:715-468-7292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2267-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist