Provider Demographics
NPI:1720646151
Name:DEITZ, KYSA LYNDELL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KYSA
Middle Name:LYNDELL
Last Name:DEITZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E2606 1151ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOYCEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54725-9473
Mailing Address - Country:US
Mailing Address - Phone:715-931-8479
Mailing Address - Fax:
Practice Address - Street 1:1625 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-8407
Practice Address - Country:US
Practice Address - Phone:715-823-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist