Healthcare Provider Details

I. General information

NPI: 1003026121
Provider Name (Legal Business Name): KELLY JO LOESCH MT-BC, WMTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 JAMES DR
HARTLAND WI
53029-8310
US

IV. Provider business mailing address

W156N10531 JEFFERSON LN
GERMANTOWN WI
53022-4123
US

V. Phone/Fax

Practice location:
  • Phone: 262-367-6663
  • Fax:
Mailing address:
  • Phone: 414-651-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number82-38
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: