Provider Demographics
NPI:1073662938
Name:BOEHM MATTIA, SHELLEY (MD)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BOEHM MATTIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S CENTURY AVE STE 128
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-1249
Mailing Address - Country:US
Mailing Address - Phone:920-965-6768
Mailing Address - Fax:920-965-6769
Practice Address - Street 1:4845 MORRIS CT
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-9164
Practice Address - Country:US
Practice Address - Phone:920-965-6768
Practice Address - Fax:920-965-6769
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI396412084P0800X
261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
BB4448331OtherDEA
G01884Medicare UPIN
WI32453500Medicaid
WI32453500Medicaid