Healthcare Provider Details

I. General information

NPI: 1710808704
Provider Name (Legal Business Name): MINDFUL JOURNEYS WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 S 76TH ST STE 204
GREENFIELD WI
53220-4356
US

IV. Provider business mailing address

4810 S 76TH ST STE 204
GREENFIELD WI
53220-4356
US

V. Phone/Fax

Practice location:
  • Phone: 262-373-8035
  • Fax:
Mailing address:
  • Phone: 262-373-8035
  • Fax: 855-582-8514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHAUN SHAMBEAU
Title or Position: OWNER
Credential: LPC
Phone: 414-588-0987