Provider Demographics
NPI:1821200098
Name:KIVI, THERESA M (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:KIVI
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2935 EAST AVE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7243
Mailing Address - Country:US
Mailing Address - Phone:608-787-5572
Mailing Address - Fax:608-787-7775
Practice Address - Street 1:2935 EAST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7243
Practice Address - Country:US
Practice Address - Phone:608-787-5572
Practice Address - Fax:608-787-7775
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1395-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42720200Medicaid