Provider Demographics
NPI:1558852293
Name:DEFOUW, SHELLEY ANN (LPT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANN
Last Name:DEFOUW
Suffix:
Gender:F
Credentials:LPT
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 217
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MI
Mailing Address - Zip Code:49406-0217
Mailing Address - Country:US
Mailing Address - Phone:269-857-2141
Mailing Address - Fax:269-857-1802
Practice Address - Street 1:243 WILEY RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MI
Practice Address - Zip Code:49406-5108
Practice Address - Country:US
Practice Address - Phone:269-857-2141
Practice Address - Fax:269-857-1802
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist