Provider Demographics
NPI:1588876320
Name:GOEBEL, KRISTINE (SLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:GOEBEL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W241S10155 MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:BIG BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53103-9569
Mailing Address - Country:US
Mailing Address - Phone:262-662-3354
Mailing Address - Fax:262-662-3354
Practice Address - Street 1:500 INTERCHANGE N
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-8922
Practice Address - Country:US
Practice Address - Phone:262-249-5860
Practice Address - Fax:262-249-5870
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1615154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42761100Medicaid