Provider Demographics
NPI:1245739846
Name:MCMANAMAN, SHANE MICHAEL
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:MCMANAMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15023 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5024
Mailing Address - Country:US
Mailing Address - Phone:586-286-9644
Mailing Address - Fax:
Practice Address - Street 1:15023 21 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-5024
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:586-286-9647
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011018225X00000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No156F00000XEye and Vision Services ProvidersTechnician/Technologist