Provider Demographics
NPI:1669627352
Name:WILLIS, SHELLEY MARIE (MA)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W. WISCONSIN AVE.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1997
Mailing Address - Country:US
Mailing Address - Phone:414-266-2919
Mailing Address - Fax:
Practice Address - Street 1:9000 W. WISCONSIN AVE.
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53201-1997
Practice Address - Country:US
Practice Address - Phone:414-266-2919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI262-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41132600Medicaid
WI41132600Medicaid
ILK00871Medicare PIN
WI41132600Medicaid