Provider Demographics
NPI:1609038611
Name:RAITZ, SHELLY JEAN (MA)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:JEAN
Last Name:RAITZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1617
Mailing Address - Country:US
Mailing Address - Phone:989-463-4971
Mailing Address - Fax:
Practice Address - Street 1:608 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1600
Practice Address - Country:US
Practice Address - Phone:989-466-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013709103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling