Provider Demographics
NPI:1275742066
Name:KELLEY-POULOS, SHANNON RAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RAE
Last Name:KELLEY-POULOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3014
Mailing Address - Country:US
Mailing Address - Phone:414-271-9791
Mailing Address - Fax:414-271-1299
Practice Address - Street 1:1216 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3014
Practice Address - Country:US
Practice Address - Phone:414-271-9791
Practice Address - Fax:414-271-1299
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health