Provider Demographics
NPI:1790860906
Name:RETKOWSKI, ELISSA ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:ANN
Last Name:RETKOWSKI
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:ELISSA
Other - Middle Name:ANN
Other - Last Name:RETKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9035 N BETHANNE DR
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2222
Mailing Address - Country:US
Mailing Address - Phone:414-479-9330
Mailing Address - Fax:414-259-0575
Practice Address - Street 1:1000 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3533
Practice Address - Country:US
Practice Address - Phone:414-479-9330
Practice Address - Fax:414-259-0575
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2257-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist