Basic Information
| Provider Information | |||||||||
| NPI: | 1063844298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADLEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARGARET ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5326 WHIPTAIL ST APT A | ||||||||
| Address2: | |||||||||
| City: | FORT IRWIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923102244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609797269 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 E WASHINGTON ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481042057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347633471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2013 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 390200000X. | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.