Provider Demographics
NPI:1548267396
Name:DREVNICK, MICHELE ANNE (MS, F-AAA)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ANNE
Last Name:DREVNICK
Suffix:
Gender:F
Credentials:MS, F-AAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 STAGELINE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7897
Mailing Address - Country:US
Mailing Address - Phone:715-531-6710
Mailing Address - Fax:715-531-6711
Practice Address - Street 1:401 STAGELINE RD
Practice Address - Street 2:SUITE 6
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7897
Practice Address - Country:US
Practice Address - Phone:715-531-6710
Practice Address - Fax:715-531-6711
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI173-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41121100Medicaid
WI900174681012OtherBLUE CROSS BS WISCONSIN
WI41121100Medicaid