Provider Demographics
NPI:1053657031
Name:SHOAF, KRISTINE MICHELLE ODDO (MA, BCBA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MICHELLE ODDO
Last Name:SHOAF
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44738 MORLEY DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1357
Mailing Address - Country:US
Mailing Address - Phone:526-421-4062
Mailing Address - Fax:586-421-4072
Practice Address - Street 1:44738 MORLEY DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1357
Practice Address - Country:US
Practice Address - Phone:526-421-4062
Practice Address - Fax:586-421-4072
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-12-10207103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst