Provider Demographics
NPI:1689987158
Name:BENSHOOF, SHELLY R (PHD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:BENSHOOF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:R
Other - Last Name:INGWERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:917 WILDWOOD LANE
Mailing Address - Street 2:SUITE 153
Mailing Address - City:NEBRASKA CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68410
Mailing Address - Country:US
Mailing Address - Phone:402-216-0561
Mailing Address - Fax:866-733-2530
Practice Address - Street 1:917 WILDWOOD LANE
Practice Address - Street 2:SUITE 153
Practice Address - City:NEBRASKA CITY
Practice Address - State:NE
Practice Address - Zip Code:68410
Practice Address - Country:US
Practice Address - Phone:402-216-0561
Practice Address - Fax:866-733-2530
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE850103T00000X
NE9177101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025465700Medicaid
NE10025287200Medicaid