Provider Demographics
NPI:1770829376
Name:SHOTSKY, DOUGLAS (PC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:SHOTSKY
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 S WINTER ST STE 1022
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3876
Mailing Address - Country:US
Mailing Address - Phone:517-264-0142
Mailing Address - Fax:517-263-7616
Practice Address - Street 1:1040 S WINTER ST STE 1022
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-264-0142
Practice Address - Fax:517-263-7616
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1000391101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional