Provider Demographics
NPI:1609269489
Name:URBAN, SHANE SCOTT
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:SCOTT
Last Name:URBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:SCOTT
Other - Last Name:URBAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APSW
Mailing Address - Street 1:316 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6516
Mailing Address - Country:US
Mailing Address - Phone:920-573-4028
Mailing Address - Fax:
Practice Address - Street 1:444 N. WESTHILL BLVD.
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-750-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127558-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical