Healthcare Provider Details

I. General information

NPI: 1558278317
Provider Name (Legal Business Name): HEIDI KOESHALL MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 W GREEN BAY ST
PULASKI WI
54162-9350
US

IV. Provider business mailing address

1619 W MARHILL RD
GREEN BAY WI
54313-6009
US

V. Phone/Fax

Practice location:
  • Phone: 920-622-6000
  • Fax:
Mailing address:
  • Phone: 262-339-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number832812
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: