Provider Demographics
NPI:1194847749
Name:QUALLS, SHELBY (CAC-1)
Entity Type:Individual
Prefix:MR
First Name:SHELBY
Middle Name:
Last Name:QUALLS
Suffix:
Gender:M
Credentials:CAC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 MORANG DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1840
Mailing Address - Country:US
Mailing Address - Phone:313-640-8084
Mailing Address - Fax:
Practice Address - Street 1:8809 JOHN C LODGE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224
Practice Address - Country:US
Practice Address - Phone:313-887-6737
Practice Address - Fax:313-876-0532
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820080101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)