=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295350817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLYANN SIIRA MUNARETTO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2020
-----------------------------------------------------
Last Update Date | 07/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 W LOIS LN
-----------------------------------------------------
City | OAK CREEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53154-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-852-8383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 W LOIS LN
-----------------------------------------------------
City | OAK CREEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53154-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 14261770
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------