Basic Information
| Provider Information | |||||||||
| NPI: | 1881764025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHULTZ | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOGILKA | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 744 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 926 WILLARD DR | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205929330 | ||||||||
| FaxNumber: | 9205929320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2727154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 42571800 | 05 | WI | MEDICAID |