Provider Demographics
NPI:1265861637
Name:HARTMAN, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48767-9729
Mailing Address - Country:US
Mailing Address - Phone:989-674-2258
Mailing Address - Fax:
Practice Address - Street 1:5750 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48767-9729
Practice Address - Country:US
Practice Address - Phone:989-674-2258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL790260639253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency