Healthcare Provider Details

I. General information

NPI: 1619137007
Provider Name (Legal Business Name): SHANA MARI CACIOPPO PSY. D, LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25507 ECORSE RD
TAYLOR MI
48180-1555
US

IV. Provider business mailing address

3401 19TH ST
WYANDOTTE MI
48192-6029
US

V. Phone/Fax

Practice location:
  • Phone: 313-292-7640
  • Fax: 313-292-9270
Mailing address:
  • Phone: 734-320-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013864
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: