Individual
BRIAN KOTHBAUER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
814 JACKSON ST, STOUGHTON, WI 53589-1520
(608) 873-6448
Mailing address
323 BERGAMONT BLVD, OREGON, WI 53575-3849
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
2799-154
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42585200
—
WI
Enumeration date
05/21/2007
Last updated
07/09/2007
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