Healthcare Provider Details

I. General information

NPI: 1780188953
Provider Name (Legal Business Name): SHAWN DENISE RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM ST
BIRMINGHAM MI
48009-6332
US

IV. Provider business mailing address

28521 PRINCETON CT
MADISON HEIGHTS MI
48071-3077
US

V. Phone/Fax

Practice location:
  • Phone: 248-341-7797
  • Fax: 248-341-9012
Mailing address:
  • Phone: 248-635-5914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5201006544
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: