Healthcare Provider Details

I. General information

NPI: 1417339250
Provider Name (Legal Business Name): CATHY J PETTIBONE MS/CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2015
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date: 07/08/2026
Reactivation Date: 07/31/2026

III. Provider practice location address

1500 4TH ST
BELOIT WI
53511-4418
US

IV. Provider business mailing address

13 W MAPLE LN
MILTON WI
53563-1643
US

V. Phone/Fax

Practice location:
  • Phone: 608-361-3600
  • Fax:
Mailing address:
  • Phone: 608-361-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2197-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: