Provider Demographics
NPI:1851516678
Name:ROETHE, LYNN ANN (MS, CCC)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:ANN
Last Name:ROETHE
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:MISS
Other - First Name:LYNN
Other - Middle Name:ANN
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC
Mailing Address - Street 1:1500 HIGHLAND AVE
Mailing Address - Street 2:ROOM S101
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2274
Mailing Address - Country:US
Mailing Address - Phone:608-263-5760
Mailing Address - Fax:608-263-5884
Practice Address - Street 1:1500 HIGHLAND AVE
Practice Address - Street 2:ROOM S101
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2274
Practice Address - Country:US
Practice Address - Phone:608-263-5760
Practice Address - Fax:608-263-5884
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI179-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42691800Medicaid