Provider Demographics
NPI:1699750612
Name:WILLIAMS, SHANIE L (PT)
Entity type:Individual
Prefix:
First Name:SHANIE
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANIE
Other - Middle Name:L
Other - Last Name:POLASIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3263 EATON ROAD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8046
Practice Address - Country:US
Practice Address - Phone:920-433-6700
Practice Address - Fax:920-433-6769
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400195780Medicare Oscar/Certification
WIK400263476Medicare Oscar/Certification
WIQ06490Medicare UPIN