Provider Demographics
NPI:1255627279
Name:SHAY, NICOLE LYNN (PHD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:SHAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE # SUIET406
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-7674
Mailing Address - Fax:262-928-5580
Practice Address - Street 1:721 AMERICAN AVE STE 406
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-7674
Practice Address - Fax:262-928-5580
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3519103TC2200X, 103TC0700X
RIPS01245103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPS01245OtherPROFESSIONAL LICENSE