Provider Demographics
NPI:1720589476
Name:MEQUON SPEECH AND LEARNING CONNECTION
Entity Type:Organization
Organization Name:MEQUON SPEECH AND LEARNING CONNECTION
Other - Org Name:MILWAUKEE MYO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HERKLOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP, COM
Authorized Official - Phone:262-302-4166
Mailing Address - Street 1:1025 W GLEN OAKS LN STE 107
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3372
Mailing Address - Country:US
Mailing Address - Phone:262-302-4166
Mailing Address - Fax:
Practice Address - Street 1:1025 W GLEN OAKS LN STE 107
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3372
Practice Address - Country:US
Practice Address - Phone:262-302-4166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497112122OtherNPI
1487843074OtherNPI