Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156F00000X | Technician/Technologist | ||
Y | 225X00000X | Occupational Therapist | 5201011018 | MI |
NPI | 1245739846 |
---|---|
Provider Name | Shane Michael Mcmanaman |
First Address | Shelby Township, MI 48315-5024 |
Second Address | Shelby Township, MI 48315-5024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2018 |
Last Update Date | 19/10/2020 |