Provider Demographics
NPI:1790071595
Name:SHELAFOE, PETER MICHAEL (LMSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:SHELAFOE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 CHIPPEWA SQ STE 208
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4824
Mailing Address - Country:US
Mailing Address - Phone:906-869-3082
Mailing Address - Fax:
Practice Address - Street 1:710 CHIPPEWA SQ STE 208
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-869-3082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010931701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical