Basic Information
| Provider Information | |||||||||
| NPI: | 1912015553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIESOW | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA-CCCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLOOM | ||||||||
| OtherFirstName: | ANN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 3 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146476326 | ||||||||
| FaxNumber: | 4146718860 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530663994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625692300 | ||||||||
| FaxNumber: | 2625692266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 231H00000X | 461-156 | WI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 41149700 | 05 | WI | MEDICAID |