Provider Demographics
NPI:1346596400
Name:O'BRIEN, SHANE DENIS
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:DENIS
Last Name:O'BRIEN
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 1:1138 LONG LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 1/2 E GRAND RIVER AVE
Practice Address - Street 2:SUITE 19
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-4323
Practice Address - Country:US
Practice Address - Phone:517-203-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist