Provider Demographics
NPI:1205576618
Name:DIAMOND, SHELBI DALE (SST)
Entity type:Individual
Prefix:MRS
First Name:SHELBI
Middle Name:DALE
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:SST
Other - Prefix:MS
Other - First Name:SHELBI
Other - Middle Name:DALE
Other - Last Name:DYKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:315 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1425
Mailing Address - Country:US
Mailing Address - Phone:616-844-8965
Mailing Address - Fax:
Practice Address - Street 1:11652 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-8465
Practice Address - Country:US
Practice Address - Phone:616-248-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803088638171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator