Healthcare Provider Details

I. General information

NPI: 1073662938
Provider Name (Legal Business Name): SHELLEY BOEHM MATTIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 MORRIS CT
WAUNAKEE WI
53597-9164
US

IV. Provider business mailing address

215 S CENTURY AVE STE 128
WAUNAKEE WI
53597-1249
US

V. Phone/Fax

Practice location:
  • Phone: 920-965-6768
  • Fax: 920-965-6769
Mailing address:
  • Phone: 920-965-6768
  • Fax: 920-965-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number39641
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: