Provider Demographics
NPI:1427410992
Name:SHELLEY BOEHM MATTIA MD,ADULT PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:SHELLEY BOEHM MATTIA MD,ADULT PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:BOEHM MATTIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-246-4925
Mailing Address - Street 1:428 DOTY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4509
Mailing Address - Country:US
Mailing Address - Phone:920-965-6768
Mailing Address - Fax:920-965-6769
Practice Address - Street 1:428 DOTY ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4509
Practice Address - Country:US
Practice Address - Phone:920-965-6768
Practice Address - Fax:920-965-6769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39641261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32453500Medicaid
WIG01884Medicare UPIN