Provider Demographics
NPI:1770033110
Name:BOCZKOWSKI, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BOCZKOWSKI
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 1:30521 SCHOENHERR RD
Mailing Address - Street 2:100
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3161
Mailing Address - Country:US
Mailing Address - Phone:248-605-8581
Mailing Address - Fax:
Practice Address - Street 1:30521 SCHOENHERR RD
Practice Address - Street 2:100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3161
Practice Address - Country:US
Practice Address - Phone:248-605-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007839225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist