Basic Information
| Provider Information | |||||||||
| NPI: | 1063650505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPARD | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREEN | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 44 E 8TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494233575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163923197 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3491 LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494199512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697512150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2009 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.