Provider Demographics
NPI:1063844298
Name:SHADLEY, SUSAN MARGARET ELIZABETH
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARGARET ELIZABETH
Last Name:SHADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5326 WHIPTAIL ST APT A
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-2244
Mailing Address - Country:US
Mailing Address - Phone:760-979-7269
Mailing Address - Fax:
Practice Address - Street 1:500 E WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2057
Practice Address - Country:US
Practice Address - Phone:734-763-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X.1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical