Provider Demographics
NPI:1912015553
Name:KIESOW, ANN M (MA-CCCA)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:M
Last Name:KIESOW
Suffix:
Gender:F
Credentials:MA-CCCA
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:915 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3994
Practice Address - Country:US
Practice Address - Phone:262-569-2300
Practice Address - Fax:262-569-2266
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI461-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41149700Medicaid