MEDICARE: DELISA SHEPHERD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	2701138363	MI

General Provider Information

NPI Number	:	1083162929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELISA SHEPHERD

Provider Business Mailing Address
First Line	:	3050 WASHTENAW AVE
Second Line	:	STUDIO 9
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5160
Country	:	US
Telephone Number	:	734-430-0866
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 WASHTENAW AVE
Second Line	:	STUDIO 9
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5160
Country	:	US
Telephone Number	:	734-430-0866
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2016
Last Update Date	:	09/20/2016

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