Provider Demographics
NPI:1710424668
Name:BALDWIN, SHANA
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:
Other - Last Name:COWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8175 MOVIE DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-7444
Mailing Address - Country:US
Mailing Address - Phone:248-277-3005
Mailing Address - Fax:
Practice Address - Street 1:8175 MOVIE DR
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-7444
Practice Address - Country:US
Practice Address - Phone:248-277-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001107103K00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other