Doctor Name: | DR. SHELLY LYNN KOMONDOROS |
NPI Number: | 1073800777 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PH.D. |
License Number: | 3138-57 |
Business Practice Address: | 1855 S Koeller St Oshkosh, WI - 549026214 |
Business Phone Number: | 9202237350 |
Business Fax Number: | |
Mailing Address: | 1855 S Koeller St, OSHKOSH |
State: | WI |
Postal Code: | 549026214 |
Phone Number: | 9202237350 |
Fax Number: | |
NPI Enumeration Date: | 07/01/2011 |
NPI Last Update Date: | 11/15/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 3138-57 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |