Provider Demographics
NPI:1265935506
Name:BORGESON, SHELLEY (ST)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BORGESON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:ANN
Other - Last Name:LOOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:836 COUNTY ROAD D
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54028-7114
Mailing Address - Country:US
Mailing Address - Phone:715-698-2919
Mailing Address - Fax:
Practice Address - Street 1:2231 US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-3269
Practice Address - Country:US
Practice Address - Phone:800-359-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1842154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist