Provider Demographics
NPI:1245819200
Name:WESTPHAL, SHANNON BERNICE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:BERNICE
Last Name:WESTPHAL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:HUSTISFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53034-0131
Mailing Address - Country:US
Mailing Address - Phone:262-224-7721
Mailing Address - Fax:
Practice Address - Street 1:139 NORTH LAKE STREET
Practice Address - Street 2:
Practice Address - City:HUSTISFORD
Practice Address - State:WI
Practice Address - Zip Code:53034-9507
Practice Address - Country:US
Practice Address - Phone:262-226-0391
Practice Address - Fax:920-349-9031
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10144-1231041C0700X
WI131945104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker