Provider Demographics
NPI:1205881927
Name:EBENSPERGER, VICKY J (CCC MST SLP)
Entity type:Individual
Prefix:MS
First Name:VICKY
Middle Name:J
Last Name:EBENSPERGER
Suffix:
Gender:F
Credentials:CCC MST SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2735
Mailing Address - Country:US
Mailing Address - Phone:715-232-1116
Mailing Address - Fax:715-232-5987
Practice Address - Street 1:808 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2735
Practice Address - Country:US
Practice Address - Phone:715-232-1116
Practice Address - Fax:715-232-5987
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:2008-06-10
Provider Licenses
StateLicense IDTaxonomies
WI1325154235Z00000X
WI1325-154171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42750600Medicaid
WI43071900Medicaid