Provider Demographics
NPI:1083992473
Name:BRACK, SHIRLEY THERESA (NCBTMB)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:THERESA
Last Name:BRACK
Suffix:
Gender:F
Credentials:NCBTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43401 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1961
Mailing Address - Country:US
Mailing Address - Phone:586-690-0329
Mailing Address - Fax:
Practice Address - Street 1:43401 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1961
Practice Address - Country:US
Practice Address - Phone:586-690-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist