Healthcare Provider Details

I. General information

NPI: 1134036569
Provider Name (Legal Business Name): SHELBY JEAN SPALDING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15560 BAK RD
VAN BUREN TWP MI
48111-3506
US

IV. Provider business mailing address

15560 BAK RD
VAN BUREN TWP MI
48111-3506
US

V. Phone/Fax

Practice location:
  • Phone: 734-645-5143
  • Fax:
Mailing address:
  • Phone: 734-645-5143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number68411
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: