Provider Demographics
NPI:1174094791
Name:BLISS, SHANE DENNIS
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:DENNIS
Last Name:BLISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W MIER RD LOT 24
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48657-9411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9673
Practice Address - Country:US
Practice Address - Phone:989-422-0279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician