Provider Demographics
NPI:1518978675
Name:MICHAEL, SHANNON (MPT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:MICHAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5832 NORTH LAPEER RD
Practice Address - Street 2:FULL CIRCLE PHYSICAL THERAPY SUITE A
Practice Address - City:NORTH BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48461
Practice Address - Country:US
Practice Address - Phone:810-793-5282
Practice Address - Fax:810-793-5281
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist