Provider Demographics
NPI:1366142416
Name:STOLARICK, SHANNON THERESE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:THERESE
Last Name:STOLARICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 HERDA AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:53181-9692
Mailing Address - Country:US
Mailing Address - Phone:224-475-3222
Mailing Address - Fax:
Practice Address - Street 1:222 N WALNUT ST # AB
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1665
Practice Address - Country:US
Practice Address - Phone:224-475-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131742-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical