Provider Demographics
NPI:1730669714
Name:SHAFER, MELISA MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:MICHELLE
Last Name:SHAFER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BAKER-JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67236 HESS RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-8627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69045 M 62
Practice Address - Street 2:
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112-9150
Practice Address - Country:US
Practice Address - Phone:269-663-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist