Healthcare Provider Details

I. General information

NPI: 1275444887
Provider Name (Legal Business Name): SHELLY LYNE BOUTET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 W CAPITOL DR
MILWAUKEE WI
53216-2040
US

IV. Provider business mailing address

2015 N 54TH ST
MILWAUKEE WI
53208-1663
US

V. Phone/Fax

Practice location:
  • Phone: 414-438-3679
  • Fax:
Mailing address:
  • Phone: 414-393-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number177440
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: