Provider Demographics
NPI:1619137007
Name:CACIOPPO, SHANA MARI (PSY D, LLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:MARI
Last Name:CACIOPPO
Suffix:
Gender:F
Credentials:PSY D, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 19TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-6029
Mailing Address - Country:US
Mailing Address - Phone:734-320-9562
Mailing Address - Fax:
Practice Address - Street 1:25507 ECORSE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-1555
Practice Address - Country:US
Practice Address - Phone:313-292-7640
Practice Address - Fax:313-292-9270
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013864103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical