Basic Information
Provider Information | |||||||||
NPI: | 1972029262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALKER | ||||||||
FirstName: | SHANE | ||||||||
MiddleName: | WILLIAM | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LLCMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1408 CUMMER ST | ||||||||
Address2: |   | ||||||||
City: | CADILLAC | ||||||||
State: | MI | ||||||||
PostalCode: | 496011769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2314293870 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 789 N CLARE AVE | ||||||||
Address2: |   | ||||||||
City: | HARRISON | ||||||||
State: | MI | ||||||||
PostalCode: | 486258250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895392141 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2017 | ||||||||
LastUpdateDate: | 01/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801101639 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.