Healthcare Provider Details

I. General information

NPI: 1982773131
Provider Name (Legal Business Name): KIMBERLY HOLTZ MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1673 DOUSMAN ST
GREEN BAY WI
54303-3209
US

IV. Provider business mailing address

1673 DOUSMAN ST
GREEN BAY WI
54303-3209
US

V. Phone/Fax

Practice location:
  • Phone: 920-498-2599
  • Fax:
Mailing address:
  • Phone: 920-498-2599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1788-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: