Provider Demographics
NPI:1457696304
Name:SHOTKIN, GAYLE (MSW, APSW)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:SHOTKIN
Suffix:
Gender:F
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:
Practice Address - Street 1:39500 W 10 MILE RD STE 110
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2947
Practice Address - Country:US
Practice Address - Phone:248-330-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128646-121104100000X
MI6801096357104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A37669Medicare PIN