Healthcare Provider Details

I. General information

NPI: 1114589538
Provider Name (Legal Business Name): MICHELLE HERUM MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 W RIVER WOODS PKWY
GLENDALE WI
53212-1088
US

IV. Provider business mailing address

4859 N IDLEWILD AVE
WHITEFISH BAY WI
53217-5958
US

V. Phone/Fax

Practice location:
  • Phone: 262-923-7101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4519154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: