Provider Demographics
NPI:1811663578
Name:BRAINSPAN
Entity type:Organization
Organization Name:BRAINSPAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAWVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-469-0636
Mailing Address - Street 1:2415 UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:43615-2331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5301 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty