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General NPI Number Information
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NPI Number | 1013804426
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Entity Type | Individual
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Provider Name | CHARLOTTE MARIA SHANAVER PHD; LP; HSP
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Gender | Female
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Dates
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Enumeration Date | 06/18/2025
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Last Update Date | 06/18/2025
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Provider Practice Location Address
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Address Line | 3365 S 103RD ST
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City | MILWAUKEE
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State | WI
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Zip | 53227-4161
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Country | US
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Telephone | 414-604-7500
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Fax |
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Provider Business Mailing Address
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Address Line | 24320 64TH PL
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City | SALEM
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State | WI
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Zip | 53168-9668
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Country | US
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Telephone | 262-758-1438
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 5246-57
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License Number State | WI
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