Provider Demographics
NPI:1285655928
Name:MATZDORF, LAURIE ANN (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:MATZDORF
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 1:6630 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3036
Mailing Address - Country:US
Mailing Address - Phone:608-263-8410
Mailing Address - Fax:608-261-5640
Practice Address - Street 1:6630 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3036
Practice Address - Country:US
Practice Address - Phone:608-263-8410
Practice Address - Fax:608-261-5640
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1166-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1166-154OtherSPEECH