Provider Demographics
NPI:1225051741
Name:PIASECKI, SHELLEY D (MD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:D
Last Name:PIASECKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 RIVERFRONT DRIVE
Mailing Address - Street 2:SHEBOYGAN
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-1679
Mailing Address - Country:US
Mailing Address - Phone:920-457-5703
Mailing Address - Fax:
Practice Address - Street 1:751 COUNTY ROAD K
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-6007
Practice Address - Country:US
Practice Address - Phone:920-929-6716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43695-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34522500Medicaid
14823OtherNETWORK HEALTH PLAN
WI34522500Medicaid
I10003Medicare UPIN