Provider Demographics
NPI:1912116179
Name:SHATZ, MARK WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
Last Name:SHATZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:33505 W 14 MILE RD
Mailing Address - Street 2:SUITE 70
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1588
Mailing Address - Country:US
Mailing Address - Phone:248-661-3300
Mailing Address - Fax:248-661-9209
Practice Address - Street 1:33505 W 14 MILE RD
Practice Address - Street 2:SUITE 70
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-1588
Practice Address - Country:US
Practice Address - Phone:248-661-3300
Practice Address - Fax:248-661-9209
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6301005043103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist