Healthcare Provider Details

I. General information

NPI: 1437708625
Provider Name (Legal Business Name): ABIGAIL RAE CRIDELICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 E FOREST ST
OCONOMOWOC WI
53066-3888
US

IV. Provider business mailing address

641 E FOREST ST
OCONOMOWOC WI
53066-3888
US

V. Phone/Fax

Practice location:
  • Phone: 262-560-3100
  • Fax:
Mailing address:
  • Phone: 262-560-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5236-154
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCF6870
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: