Provider Demographics
NPI:1851332076
Name:ALLEN, RENEE D (MS CFY - SLP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:D
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MS CFY - SLP
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:D
Other - Last Name:JUNGWIRTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CFY - SLP
Mailing Address - Street 1:430 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-5370
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-5370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2632-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42566100Medicaid