MEDICARE: MS. ANGELA KONGSHAUG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1275817298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELA KONGSHAUG

Provider Business Mailing Address
First Line	:	4102 WASHINGTON RD
Second Line	:	APT. 110
City	:	KENOSHA
State	:	WI
Zip	:	53144-1522
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4102 WASHINGTON RD
Second Line	:	APT. 110
City	:	KENOSHA
State	:	WI
Zip	:	53144-1522
Country	:	US
Telephone Number	:	262-497-2067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2011
Last Update Date	:	10/10/2011

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Directions to “ MS. ANGELA KONGSHAUG ” Practice Location

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