Provider Demographics
NPI:1821313859
Name:GALLENBERG, SHELLY A (PHD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:GALLENBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6785
Mailing Address - Country:US
Mailing Address - Phone:715-848-4600
Mailing Address - Fax:715-845-5398
Practice Address - Street 1:1225 LANGLADE RD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2762
Practice Address - Country:US
Practice Address - Phone:715-627-6694
Practice Address - Fax:715-627-6645
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4293-125101YP2500X
WI3111103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4293-125OtherSTATE LICENSE
WI3111OtherSTATE LICENSE