Healthcare Provider Details

I. General information

NPI: 1316757180
Provider Name (Legal Business Name): SHAYLIE HANSEN SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 COUNTY ROAD DF FL 3
JUNEAU WI
53039-9512
US

IV. Provider business mailing address

610 W BURNETT ST
BEAVER DAM WI
53916-1656
US

V. Phone/Fax

Practice location:
  • Phone: 920-386-3500
  • Fax: 920-386-4564
Mailing address:
  • Phone: 920-296-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17354-132
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9026-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: