Provider Demographics
NPI:1891032058
Name:ZERTLER, SHANE ARTHUR
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ARTHUR
Last Name:ZERTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:136 W BROADWAY
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-0297
Mailing Address - Country:US
Mailing Address - Phone:715-748-4535
Mailing Address - Fax:
Practice Address - Street 1:136 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1757
Practice Address - Country:US
Practice Address - Phone:715-316-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1181-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional