Provider Demographics
NPI:1558535583
Name:LONERGAN, KELLY (MS, CCC-SLP, C/NDT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LONERGAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP, C/NDT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:THOMASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:410 PARK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-1635
Mailing Address - Country:US
Mailing Address - Phone:608-218-5631
Mailing Address - Fax:
Practice Address - Street 1:200 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1962
Practice Address - Country:US
Practice Address - Phone:608-218-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3022-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41205000Medicaid