Provider Demographics
NPI:1417339250
Name:(WILSON) PETTIBONE, CATHY J (MS/CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:CATHY
Middle Name:J
Last Name:(WILSON) PETTIBONE
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 1:8006 N JOHN PAUL RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-9259
Mailing Address - Country:US
Mailing Address - Phone:608-206-5831
Mailing Address - Fax:
Practice Address - Street 1:400 N MORRIS ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1857
Practice Address - Country:US
Practice Address - Phone:608-873-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-28
Last Update Date:2015-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2197-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist