Provider Demographics
NPI:1083162929
Name:SHEPHERD, DELISA
Entity Type:Individual
Prefix:
First Name:DELISA
Middle Name:
Last Name:SHEPHERD
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 1:3050 WASHTENAW AVE
Mailing Address - Street 2:STUDIO 9
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5160
Mailing Address - Country:US
Mailing Address - Phone:734-430-0866
Mailing Address - Fax:
Practice Address - Street 1:3050 WASHTENAW AVE
Practice Address - Street 2:STUDIO 9
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5160
Practice Address - Country:US
Practice Address - Phone:734-430-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI27011383631744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management