Provider Demographics
NPI:1922373737
Name:HANSEN, SHELLEY (MPT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12520 STEPHEN PL
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1961
Mailing Address - Country:US
Mailing Address - Phone:262-938-0657
Mailing Address - Fax:
Practice Address - Street 1:10150 W NATIONAL AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2145
Practice Address - Country:US
Practice Address - Phone:414-431-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4503-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist