Healthcare Provider Details

I. General information

NPI: 1720589476
Provider Name (Legal Business Name): MEQUON SPEECH AND LEARNING CONNECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W GLEN OAKS LN STE 107
MEQUON WI
53092-3372
US

IV. Provider business mailing address

1025 W GLEN OAKS LN STE 107
MEQUON WI
53092-3372
US

V. Phone/Fax

Practice location:
  • Phone: 262-302-4166
  • Fax:
Mailing address:
  • Phone: 262-302-4166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER HERKLOTZ
Title or Position: OWNER
Credential: MA CCC-SLP, COM
Phone: 262-302-4166