Healthcare Provider Details

I. General information

NPI: 1114241585
Provider Name (Legal Business Name): JOHN SHAFER LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 FORT ST
TRENTON MI
48183
US

IV. Provider business mailing address

1660 FORT ST
TRENTON MI
48183-2003
US

V. Phone/Fax

Practice location:
  • Phone: 734-304-4159
  • Fax:
Mailing address:
  • Phone: 734-304-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301014377
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number6301014377
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: