Provider Demographics
NPI:1033169008
Name:SHULL-BLOOD, PATRICIA (LLP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SHULL-BLOOD
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 LOVERS LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1572
Mailing Address - Country:US
Mailing Address - Phone:269-343-3010
Mailing Address - Fax:269-343-3017
Practice Address - Street 1:5148 LOVERS LN
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1572
Practice Address - Country:US
Practice Address - Phone:269-343-3010
Practice Address - Fax:269-343-3017
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010066103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP108918030OtherBCBSM