Provider Demographics
NPI:1356723993
Name:SHELLEY, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHELLEY
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 1:173 E WOODLAND ST
Mailing Address - Street 2:#1
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1473
Mailing Address - Country:US
Mailing Address - Phone:248-683-7374
Mailing Address - Fax:313-532-3124
Practice Address - Street 1:17150 INKSTER RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2328
Practice Address - Country:US
Practice Address - Phone:313-532-3118
Practice Address - Fax:313-532-3124
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other