Healthcare Provider Details

I. General information

NPI: 1992505358
Provider Name (Legal Business Name): SHAWNTELL NICOLE PACE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-777-7700
  • Fax: 414-955-0114
Mailing address:
  • Phone: 414-777-7700
  • Fax: 414-955-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5316-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: