Healthcare Provider Details

I. General information

NPI: 1255709671
Provider Name (Legal Business Name): SHEA NIEDECKEN LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 W BRISTOL RD
FLINT MI
48507-5516
US

IV. Provider business mailing address

1040 W BRISTOL RD
FLINT MI
48507-5516
US

V. Phone/Fax

Practice location:
  • Phone: 810-496-4955
  • Fax:
Mailing address:
  • Phone: 810-288-2726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802090635
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: