Basic Information
| Provider Information | |||||||||
| NPI: | 1104364793 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HASKINS | ||||||||
| FirstName: | SHANON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3320 PINE MEADOW DR SE | ||||||||
| Address2: | APT 103 | ||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495123079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166172622 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1490 E BELTLINE AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495064336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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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 | 225800000X | 56956 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist |
No ID Information.