Healthcare Provider Details

I. General information

NPI: 1962366740
Provider Name (Legal Business Name): REBECCA SHORTREED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W MARKET ST STE 110
MEQUON WI
53092-5053
US

IV. Provider business mailing address

1975 FARMLANE DR
SLINGER WI
53086-3003
US

V. Phone/Fax

Practice location:
  • Phone: 262-388-3666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8127-403
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: