=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265861637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY HARTMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2013
-----------------------------------------------------
Last Update Date | 11/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5750 SHERIDAN RD
-----------------------------------------------------
City | UNIONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48767-9729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-674-2258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5750 SHERIDAN RD
-----------------------------------------------------
City | UNIONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48767-9729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-674-2258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number | AL790260639
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------