Healthcare Provider Details

I. General information

NPI: 1942874060
Provider Name (Legal Business Name): SHAESHA SHOULDERS LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 N MAIN ST
MOUNT CLEMENS MI
48043-5613
US

IV. Provider business mailing address

1571 S BASSETT ST
DETROIT MI
48217-1642
US

V. Phone/Fax

Practice location:
  • Phone: 586-404-4449
  • Fax: 586-501-1664
Mailing address:
  • Phone: 313-989-6746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801107639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: