Provider Demographics
NPI:1518590280
Name:MCMICHAEL, SHALYN JANEL
Entity Type:Individual
Prefix:
First Name:SHALYN
Middle Name:JANEL
Last Name:MCMICHAEL
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 1:16 PALMETTO PINES LN
Mailing Address - Street 2:
Mailing Address - City:RAY CITY
Mailing Address - State:GA
Mailing Address - Zip Code:31645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2209 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7316
Practice Address - Country:US
Practice Address - Phone:229-671-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
60173225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist