MEDICARE: DR. SHANNON RAE KELLEY-POULOS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1275742066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON RAE KELLEY-POULOS PSYD

Provider Business Mailing Address
First Line	:	1216 N PROSPECT AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3014
Country	:	US
Telephone Number	:	414-271-9791
Fax Number	:	414-271-1299

Provider Business Practice Location Address
First Line	:	1216 N PROSPECT AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3014
Country	:	US
Telephone Number	:	414-271-9791
Fax Number	:	414-271-1299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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