Provider Demographics
NPI:1891196374
Name:LEE-BJERKE, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:LEE-BJERKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 N LARK ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-3349
Mailing Address - Country:US
Mailing Address - Phone:920-859-0269
Mailing Address - Fax:
Practice Address - Street 1:500 GRANT AVE
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-1342
Practice Address - Country:US
Practice Address - Phone:920-859-0269
Practice Address - Fax:920-859-0279
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4016-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist