Provider Demographics
NPI:1689133084
Name:WALTER, SHAE (LMT)
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14090 LAKESIDE BLVD N
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6071
Mailing Address - Country:US
Mailing Address - Phone:586-991-1759
Mailing Address - Fax:
Practice Address - Street 1:14090 LAKESIDE BLVD N
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-6071
Practice Address - Country:US
Practice Address - Phone:586-991-1759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist