Basic Information
| Provider Information | |||||||||
| NPI: | 1376038596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHINE | ||||||||
| FirstName: | KALI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19395 W CAPITOL DR STE 2000 | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629237101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1223 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539162629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208854750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.