Provider Demographics
NPI:1659128221
Name:BLUE, SHENISE MARIE
Entity type:Individual
Prefix:
First Name:SHENISE
Middle Name:MARIE
Last Name:BLUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 STONEBROOK DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-7208
Mailing Address - Country:US
Mailing Address - Phone:404-481-7694
Mailing Address - Fax:
Practice Address - Street 1:540 JENNER DR
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1517
Practice Address - Country:US
Practice Address - Phone:269-686-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator