Provider Demographics
NPI:1902121049
Name:CHARBONEAU, SHELLIE (CMT)
Entity Type:Individual
Prefix:MRS
First Name:SHELLIE
Middle Name:
Last Name:CHARBONEAU
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S HURON ST STE C
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-1979
Mailing Address - Country:US
Mailing Address - Phone:231-268-9421
Mailing Address - Fax:
Practice Address - Street 1:321 S. HURON
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721
Practice Address - Country:US
Practice Address - Phone:231-268-9421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist