Provider Demographics
NPI:1679603575
Name:BLACK, SHAWN MICHAEL (MS, PT)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:BLACK
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3924 LEESIDE LN
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3271 RACQUET CLUB DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4708
Practice Address - Country:US
Practice Address - Phone:231-932-9720
Practice Address - Fax:231-995-9302
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist