Provider Demographics
NPI:1265225890
Name:RANKIN, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RANKIN
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 1:41748 BROQUET DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2402
Mailing Address - Country:US
Mailing Address - Phone:248-679-6312
Mailing Address - Fax:
Practice Address - Street 1:835 MASON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2231
Practice Address - Country:US
Practice Address - Phone:313-561-9064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010158103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist