1710101258 NPI number — MS. MARY KATHERINE SHEGAN LMSW ACSW

Table of content: MS. MARY KATHERINE SHEGAN LMSW ACSW (NPI 1710101258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710101258 NPI number — MS. MARY KATHERINE SHEGAN LMSW ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEGAN
Provider First Name:
MARY
Provider Middle Name:
KATHERINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW ACSW
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:
1710101258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8244 S AGATE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROUT CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-852-3485
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13958 US HWY 45
Provider Second Line Business Practice Location Address:
WAKEFIELD
Provider Business Practice Location Address City Name:
BRUCE CROSSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49912-0128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-852-3485
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007

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: 1041C0700X , with the licence number:  6801012151 , 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)





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