Provider Demographics
NPI:1487827382
Name:KIRSCHBAUM, MARY LEIGH (MS/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LEIGH
Last Name:KIRSCHBAUM
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:205 PRAIRIE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3406
Mailing Address - Country:US
Mailing Address - Phone:920-296-4889
Mailing Address - Fax:920-356-0621
Practice Address - Street 1:410 ROEDL COURT
Practice Address - Street 2:GOLDEN LIVING CENTER
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-887-7191
Practice Address - Fax:920-887-7270
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI89-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41220500Medicaid