Healthcare Provider Details

I. General information

NPI: 1619772795
Provider Name (Legal Business Name): SHANELLE MCGINNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

640 FIFTH ST NW
GRAND RAPIDS MI
49504-5186
US

IV. Provider business mailing address

4602 BROOKMEADOW DR SE
KENTWOOD MI
49512-5427
US

V. Phone/Fax

Practice location:
  • Phone: 616-647-5257
  • Fax:
Mailing address:
  • Phone: 616-432-4873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: