Healthcare Provider Details

I. General information

NPI: 1780508218
Provider Name (Legal Business Name): SHELBY LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22520 LAKE BLVD
SAINT CLAIR SHORES MI
48082-2721
US

IV. Provider business mailing address

22520 LAKE BLVD
SAINT CLAIR SHORES MI
48082-2721
US

V. Phone/Fax

Practice location:
  • Phone: 810-434-4278
  • Fax:
Mailing address:
  • Phone: 810-434-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101005222
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: