Provider Demographics
NPI:1841451317
Name:MITTELSTAEDT, LORRIE L (MS, CCC-SLP, BCBA)
Entity type:Individual
Prefix:MRS
First Name:LORRIE
Middle Name:L
Last Name:MITTELSTAEDT
Suffix:
Gender:F
Credentials:MS, CCC-SLP, BCBA
Other - Prefix:MRS
Other - First Name:LORRIE
Other - Middle Name:
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 VIKING DR
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1675
Mailing Address - Country:US
Mailing Address - Phone:608-524-9600
Mailing Address - Fax:608-524-3697
Practice Address - Street 1:420 VIKING DR
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1675
Practice Address - Country:US
Practice Address - Phone:608-524-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4500-154235Z00000X
WI182-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-2300706Medicaid