Healthcare Provider Details

I. General information

NPI: 1225523814
Provider Name (Legal Business Name): SHANTEE M WILBURN QMHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 DETROIT AVE
CLEVELAND OH
44102-1852
US

IV. Provider business mailing address

473 E 149TH ST
CLEVELAND OH
44110-1859
US

V. Phone/Fax

Practice location:
  • Phone: 216-283-4400
  • Fax: 216-283-5359
Mailing address:
  • Phone: 216-512-5491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: