Provider Demographics
NPI:1689275380
Name:SUTPHEN, SHELBY LYNN
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:SUTPHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11172 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-9163
Mailing Address - Country:US
Mailing Address - Phone:616-510-2157
Mailing Address - Fax:
Practice Address - Street 1:2775 E LANSING DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7755
Practice Address - Country:US
Practice Address - Phone:517-332-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician