Provider Demographics
NPI:1700228236
Name:GIBSON, SHALETA ELAINE (AUD)
Entity Type:Individual
Prefix:
First Name:SHALETA
Middle Name:ELAINE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SHALETA
Other - Middle Name:ELAINE
Other - Last Name:HAVARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:3621 S STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:1ST FLOOR MED INN RM C166A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5816
Practice Address - Country:US
Practice Address - Phone:734-936-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000648231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist