Provider Demographics
NPI:1598977613
Name:ANDERSON, BETH ANN (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N164W20505 CURRANT LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-8987
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1119 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1209
Practice Address - Country:US
Practice Address - Phone:262-284-5892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2872-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42581700Medicaid