1427647825 NPI number — MS. SHANNON RENEE OLSON WIETRZNY LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427647825 NPI number — MS. SHANNON RENEE OLSON WIETRZNY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIETRZNY
Provider First Name:
SHANNON
Provider Middle Name:
RENEE OLSON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARRETSON
Provider Other First Name:
SHANNON
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427647825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N24W23870 TALON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188-1830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-320-3098
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N17W24222 RIVERWOOD DR STE 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-320-3098
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  8467-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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