Healthcare Provider Details

I. General information

NPI: 1407227689
Provider Name (Legal Business Name): ELIZABETH SHARK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH LANDA

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15520 19 MILE RD STE 450
CLINTON TWP MI
48038-6332
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 586-416-2000
  • Fax: 586-416-2013
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: