Healthcare Provider Details

I. General information

NPI: 1437638855
Provider Name (Legal Business Name): ANGELA MACUMBER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA DODERO M.S. CCC-SLP

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 2ND ST
NEENAH WI
54956-2883
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-850-8498
  • Fax:
Mailing address:
  • Phone: 920-850-8498
  • Fax: 920-720-7350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12126
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5389
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: