MEDICARE: SHANELL CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171M00000X	Case Manager/Care Coordinator
2	372500000X	Chore Provider
3	373H00000X	Day Training/Habilitation Specialist
4	376G00000X	Nursing Home Administrator

General Provider Information

NPI Number	:	1972958106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANELL CLARK

Provider Business Mailing Address
First Line	:	21820 BEVERLY ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2503
Country	:	US
Telephone Number	:	248-234-6150
Fax Number	:

Provider Business Practice Location Address
First Line	:	21820 BEVERLY ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2503
Country	:	US
Telephone Number	:	248-234-6150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2016
Last Update Date	:	04/25/2016

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Directions to “ SHANELL CLARK ” Practice Location

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