Provider Demographics
NPI:1235121260
Name:STATZ, SHELLY ROSE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:ROSE
Last Name:STATZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 MONDOVI RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6141
Mailing Address - Country:US
Mailing Address - Phone:715-832-0238
Mailing Address - Fax:715-832-0771
Practice Address - Street 1:2910 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4538
Practice Address - Country:US
Practice Address - Phone:715-381-5437
Practice Address - Fax:715-381-5438
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7021-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
114321498OtherCAQH