Provider Demographics
NPI:1356507776
Name:SHOUP, DAVID (ACSW)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:SHOUP
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 PACKARD ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1521
Mailing Address - Country:US
Mailing Address - Phone:734-971-9781
Mailing Address - Fax:734-971-2730
Practice Address - Street 1:4925 PACKARD ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1521
Practice Address - Country:US
Practice Address - Phone:734-971-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010821911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11879123OtherCAQH
MIP24010020Medicare UPIN