Provider Demographics
NPI:1184871378
Name:KETELHUT, SHELLY LYNN (MSE, NCC, CSAC)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:LYNN
Last Name:KETELHUT
Suffix:
Gender:F
Credentials:MSE, NCC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936B ALGOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2104
Mailing Address - Country:US
Mailing Address - Phone:920-232-0208
Mailing Address - Fax:844-270-4612
Practice Address - Street 1:1936B ALGOMA BLVD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2104
Practice Address - Country:US
Practice Address - Phone:920-232-0208
Practice Address - Fax:844-270-4612
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4498-125101YP2500X
WI15566-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional