Provider Demographics
NPI:1871468009
Name:SHANKS, TERELL
Entity type:Individual
Prefix:
First Name:TERELL
Middle Name:
Last Name:SHANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24225 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3962
Mailing Address - Country:US
Mailing Address - Phone:248-915-4513
Mailing Address - Fax:
Practice Address - Street 1:12880 DOLPHIN ST APT 1
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-3124
Practice Address - Country:US
Practice Address - Phone:248-915-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty