Provider Demographics
NPI:1265420491
Name:SHEA, NANCY (LCSW)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SHERMAN AVE E
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1960
Mailing Address - Country:US
Mailing Address - Phone:920-568-6558
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:200 E TYRANENA PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-9678
Practice Address - Country:US
Practice Address - Phone:920-648-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16971041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39634600Medicaid
WI1011361OtherPHYSICIANS PLUS