Provider Demographics
NPI:1548375017
Name:EDAHL, KRISTINE (MA CCC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:EDAHL
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 PINE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4120
Practice Address - Country:US
Practice Address - Phone:715-847-2600
Practice Address - Fax:715-847-2626
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI746235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42701700Medicaid
WI42701700Medicaid
WI000072200Medicare ID - Type Unspecified