Healthcare Provider Details

I. General information

NPI: 1942120225
Provider Name (Legal Business Name): SHELLY ANN SIEGEL MA-CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 LOON LAKE RD
WIXOM MI
48393-1648
US

IV. Provider business mailing address

2761 DUFFERS LN
COMMERCE TOWNSHIP MI
48390-1718
US

V. Phone/Fax

Practice location:
  • Phone: 248-956-4040
  • Fax:
Mailing address:
  • Phone: 248-506-8933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101003659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: