Provider Demographics
NPI:1407252133
Name:BERDAN, SHANDA
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:BERDAN
Suffix:
Gender:F
Credentials:
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 325
Mailing Address - Street 2:216 HEBESTREIT ST.
Mailing Address - City:ROSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48654-0325
Mailing Address - Country:US
Mailing Address - Phone:989-701-5836
Mailing Address - Fax:989-685-8363
Practice Address - Street 1:337 E HOUGHTON AVE
Practice Address - Street 2:CLINIC A
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1127
Practice Address - Country:US
Practice Address - Phone:989-701-5836
Practice Address - Fax:989-685-8363
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013102101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional