Healthcare Provider Details

I. General information

NPI: 1356707855
Provider Name (Legal Business Name): SHANITA DENISE ECCLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26300 OUTER DR
LINCOLN PARK MI
48146-2019
US

IV. Provider business mailing address

33416 SAND PIPER DR
ROMULUS MI
48174-6404
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7700
  • Fax:
Mailing address:
  • Phone: 734-502-4848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC013951
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-1012
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801106111
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: