Healthcare Provider Details

I. General information

NPI: 1598584963
Provider Name (Legal Business Name): MILES WESLEY SHANE LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34290 FORD RD
WESTLAND MI
48185-3051
US

IV. Provider business mailing address

34290 FORD RD
WESTLAND MI
48185-3051
US

V. Phone/Fax

Practice location:
  • Phone: 734-412-8800
  • Fax:
Mailing address:
  • Phone: 734-412-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451025155
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: