Provider Demographics
NPI:1548603830
Name:WITTE, KELLY (MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WITTE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 W MAIN ST
Mailing Address - Street 2:SUITE 200 GOODHUE HALL
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1705
Mailing Address - Country:US
Mailing Address - Phone:414-840-9754
Mailing Address - Fax:
Practice Address - Street 1:709 MEADOW PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WI
Practice Address - Zip Code:53525-9777
Practice Address - Country:US
Practice Address - Phone:608-676-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3729-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist