Provider Demographics
NPI:1477841971
Name:BALLWEG, KATHRYN LYNNAE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LYNNAE
Last Name:BALLWEG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:LYNNAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:677 E STATE STREET
Mailing Address - Street 2:MOUNT CARMEL
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1639
Mailing Address - Country:US
Mailing Address - Phone:262-763-9531
Mailing Address - Fax:
Practice Address - Street 1:677 E STATE STREET
Practice Address - Street 2:MOUNT CARMEL
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1639
Practice Address - Country:US
Practice Address - Phone:262-763-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3522-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist