Healthcare Provider Details

I. General information

NPI: 1912290875
Provider Name (Legal Business Name): MICHAEL TODD SHOOK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E. LIBERTY ST STE.205
ANN ARBOR MI
48104
US

IV. Provider business mailing address

200 TURWILL LN
KALAMAZOO MI
49006-4277
US

V. Phone/Fax

Practice location:
  • Phone: 269-352-9315
  • Fax:
Mailing address:
  • Phone: 269-344-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704223546
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092445
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: