1104393792 NPI number — SHAYLA NICOLE EDMOND LLMSW

Table of content: SHAYLA NICOLE EDMOND LLMSW (NPI 1104393792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104393792 NPI number — SHAYLA NICOLE EDMOND LLMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMOND
Provider First Name:
SHAYLA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LLMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104393792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N WEST AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49202-2180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-789-1234
Provider Business Mailing Address Fax Number:
517-784-7040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 HOGBACK ROAD
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-956-0051
Provider Business Practice Location Address Fax Number:
888-976-6019
Provider Enumeration Date:
11/01/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)