Provider Demographics
NPI:1235488529
Name:BAILEY, SHELLY LAONE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:LAONE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-0009
Mailing Address - Country:US
Mailing Address - Phone:252-363-8223
Mailing Address - Fax:
Practice Address - Street 1:526 S ALGER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-9605
Practice Address - Country:US
Practice Address - Phone:252-363-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-03
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010938091041C0700X
NCC0068191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical