Provider Demographics
NPI:1972941771
Name:SHIPMAN, RAYVON LARNARD (BS)
Entity Type:Individual
Prefix:MR
First Name:RAYVON
Middle Name:LARNARD
Last Name:SHIPMAN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11648 WHITTIER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1540
Mailing Address - Country:US
Mailing Address - Phone:586-563-5801
Mailing Address - Fax:
Practice Address - Street 1:18121 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3245
Practice Address - Country:US
Practice Address - Phone:586-563-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086544171M00000X
MI68511157951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator