Healthcare Provider Details

I. General information

NPI: 1972029262
Provider Name (Legal Business Name): SHANE WILLIAM WALKER LLCMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 N CLARE AVE
HARRISON MI
48625-8250
US

IV. Provider business mailing address

1408 CUMMER ST
CADILLAC MI
49601-1769
US

V. Phone/Fax

Practice location:
  • Phone: 989-539-2141
  • Fax:
Mailing address:
  • Phone: 231-429-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801101639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: