Healthcare Provider Details

I. General information

NPI: 1285824581
Provider Name (Legal Business Name): SHAWN EDYVEAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N5241 US HIGHWAY 45
WATERSMEET MI
49969-0009
US

IV. Provider business mailing address

N5241 US HIGHWAY 45
WATERSMEET MI
49969-0009
US

V. Phone/Fax

Practice location:
  • Phone: 906-358-4588
  • Fax: 906-358-4118
Mailing address:
  • Phone: 906-358-4588
  • Fax: 906-358-4118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9719-024
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501010780
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: