Healthcare Provider Details

I. General information

NPI: 1508675968
Provider Name (Legal Business Name): WILLIAM ALBERT SHOPE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2024
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9198A THRALL RD
WOODRUFF WI
54568-9329
US

IV. Provider business mailing address

12308 E FITZGERALD LN
MANITOWISH WATERS WI
54545-9249
US

V. Phone/Fax

Practice location:
  • Phone: 715-439-4377
  • Fax:
Mailing address:
  • Phone: 715-904-0869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20740130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: