Healthcare Provider Details

I. General information

NPI: 1730669714
Provider Name (Legal Business Name): MELISA MICHELLE SHAFER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA BAKER-JOHNSON

II. Dates (important events)

Enumeration Date: 08/18/2018
Last Update Date: 08/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69045 M 62
EDWARDSBURG MI
49112-9150
US

IV. Provider business mailing address

67236 HESS RD
EDWARDSBURG MI
49112-8627
US

V. Phone/Fax

Practice location:
  • Phone: 269-663-2201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501010588
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: