Provider Demographics
NPI:1639575038
Name:SHAFER, IAN DAVID (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:DAVID
Last Name:SHAFER
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 HOLT RD STE 205
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-6019
Mailing Address - Country:US
Mailing Address - Phone:517-881-7231
Mailing Address - Fax:
Practice Address - Street 1:4025 HOLT RD STE 205
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-6019
Practice Address - Country:US
Practice Address - Phone:517-881-7231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012915101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health