=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588876320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINE GOEBEL SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 INTERCHANGE N
-----------------------------------------------------
City | LAKE GENEVA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53147-8922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-249-5860
-----------------------------------------------------
Fax | 262-249-5870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W241S10155 MEADOW CIR
-----------------------------------------------------
City | BIG BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53103-9569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-662-3354
-----------------------------------------------------
Fax | 262-662-3354
-----------------------------------------------------
=====================================================
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 | 1615154
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------