1114155207 NPI number — KRISTIN ELIZABETH WIKLUND MS, CCC-SLP

Table of content: KRISTIN ELIZABETH WIKLUND MS, CCC-SLP (NPI 1114155207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114155207 NPI number — KRISTIN ELIZABETH WIKLUND MS, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIKLUND
Provider First Name:
KRISTIN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRAAK
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114155207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
331 PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARENDON HILLS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60514-1309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-295-3905
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARENDON HILLS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60514-1309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-295-3905
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  3254-154 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 146011939 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: 9655 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3254-154 . This is a "SPEECH-LANGUAGE-PATHOLOGIST" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 146011939 . This is a "ILLINOIS STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".