Provider Demographics
NPI:1629204458
Name:CORRIGALL, KIM MARY (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARY
Last Name:CORRIGALL
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-2819
Mailing Address - Country:US
Mailing Address - Phone:715-498-4344
Mailing Address - Fax:
Practice Address - Street 1:107 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-2819
Practice Address - Country:US
Practice Address - Phone:715-498-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3235-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629204458Medicaid