Healthcare Provider Details

I. General information

NPI: 1760871925
Provider Name (Legal Business Name): SHANE KERBELIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5678 SASHABAW RD
CLARKSTON MI
48346-3148
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 248-922-9280
  • Fax: 248-922-9287
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002200
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: