Provider Demographics
NPI:1528231206
Name:SLACK, ELIZABETH L
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 COUNTY HIGHWAY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5407
Mailing Address - Country:US
Mailing Address - Phone:715-726-3590
Mailing Address - Fax:
Practice Address - Street 1:7490 156TH ST
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-1425
Practice Address - Country:US
Practice Address - Phone:715-726-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42788000Medicaid