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General NPI Number Information
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NPI Number | 1821313859
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Entity Type | Individual
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Provider Name | SHELLY A GALLENBERG PH.D.
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Gender | Female
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Dates
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Enumeration Date | 04/01/2010
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Last Update Date | 02/03/2014
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Provider Practice Location Address
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Address Line | 1225 LANGLADE RD
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City | ANTIGO
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State | WI
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Zip | 54409-2762
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Country | US
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Telephone | 715-627-6694
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Fax | 715-627-6645
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Provider Business Mailing Address
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Address Line | 1100 LAKE VIEW DR
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City | WAUSAU
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State | WI
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Zip | 54403-6785
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Country | US
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Telephone | 715-848-4600
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Fax | 715-845-5398
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4293-125
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3111
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License Number State | WI
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