Provider Demographics
NPI:1780188953
Name:RICHARDSON, SHAWN DENISE
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:DENISE
Last Name:RICHARDSON
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 1:28521 PRINCETON CT
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3077
Mailing Address - Country:US
Mailing Address - Phone:248-635-5914
Mailing Address - Fax:
Practice Address - Street 1:111 ELM ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6332
Practice Address - Country:US
Practice Address - Phone:248-341-7797
Practice Address - Fax:248-341-9012
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006544225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology