Healthcare Provider Details

I. General information

NPI: 1740720010
Provider Name (Legal Business Name): SHALONDA SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 LEDYARD ST
DETROIT MI
48201-2641
US

IV. Provider business mailing address

445 LEDYARD ST
DETROIT MI
48201-2641
US

V. Phone/Fax

Practice location:
  • Phone: 313-962-9446
  • Fax:
Mailing address:
  • Phone: 313-962-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: