Healthcare Provider Details

I. General information

NPI: 1124959887
Provider Name (Legal Business Name): SHIRLEY ANN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 W MAPLE RD # A
WEST BLOOMFIELD MI
48322-4302
US

IV. Provider business mailing address

6525 W MAPLE RD # A
WEST BLOOMFIELD MI
48322-4302
US

V. Phone/Fax

Practice location:
  • Phone: 248-562-7846
  • Fax:
Mailing address:
  • Phone: 248-562-7846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201007877
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: