Provider Demographics
NPI:1124844170
Name:SHOULDERS, BRIAN (DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SHOULDERS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SAND CREEK HWY APT C
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-9176
Mailing Address - Country:US
Mailing Address - Phone:517-366-9771
Mailing Address - Fax:
Practice Address - Street 1:902 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-9701
Practice Address - Country:US
Practice Address - Phone:517-423-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist