Healthcare Provider Details

I. General information

NPI: 1518978675
Provider Name (Legal Business Name): SHANNON MICHAEL MPT.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SHANNON MARIE MICHAEL

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5832 NORTH LAPEER RD FULL CIRCLE PHYSICAL THERAPY SUITE A
NORTH BRANCH MI
48461
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 810-793-5282
  • Fax: 810-793-5281
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501012116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: