Provider Demographics
NPI:1265706444
Name:PETOSKEY, MARY ELIZABETH (MS/CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:PETOSKEY
Suffix:
Gender:F
Credentials:MS/CCC-SLP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10945 N. PORT WASHINGTON RD.
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0000
Mailing Address - Country:US
Mailing Address - Phone:262-241-8000
Mailing Address - Fax:262-241-8096
Practice Address - Street 1:2900 W. OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-0000
Practice Address - Country:US
Practice Address - Phone:414-649-7772
Practice Address - Fax:414-649-7977
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI419-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist