Provider Demographics
NPI:1285019422
Name:SHEA, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SHEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 W PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-3784
Mailing Address - Country:US
Mailing Address - Phone:715-379-6323
Mailing Address - Fax:
Practice Address - Street 1:612 E OAK ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD CITY
Practice Address - State:WI
Practice Address - Zip Code:54013-8520
Practice Address - Country:US
Practice Address - Phone:715-265-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4153-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist