=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093199713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELL FREEMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2015
-----------------------------------------------------
Last Update Date | 01/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14799 DIX TOLEDO RD
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-324-8326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 618 CHRYSLER DR APT 201
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48207-3055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-778-2532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801098321
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801107854
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------