Healthcare Provider Details

I. General information

NPI: 1972995488
Provider Name (Legal Business Name): SHAUN PATRICK THOMAS WELDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2015
Last Update Date: 02/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

V. Phone/Fax

Practice location:
  • Phone: 517-420-8984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: