Basic Information
| Provider Information | |||||||||
| NPI: | 1285019422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEA | ||||||||
| FirstName: | KYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 W PRINCETON AVE | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547033784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153796323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 612 E OAK ST | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540138520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152654325 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4153-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.