Provider Demographics
NPI:1669678512
Name:DUTCH, SHELLY LYNN (CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LYNN
Last Name:DUTCH
Suffix:
Gender:F
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 APPLEGATE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3184
Mailing Address - Country:US
Mailing Address - Phone:608-221-1500
Mailing Address - Fax:608-221-1515
Practice Address - Street 1:1334 APPLEGATE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-3184
Practice Address - Country:US
Practice Address - Phone:608-221-1500
Practice Address - Fax:608-221-1515
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1047-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1047-132OtherCLINICAL SUB. ABUSE COUN
WI12230-134OtherINTERMEDIATE CLINICAL SUP