Provider Demographics
NPI:1871522961
Name:COUSINEAU, SHANE MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:COUSINEAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:997 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9375
Mailing Address - Country:US
Mailing Address - Phone:989-732-2225
Mailing Address - Fax:989-731-6776
Practice Address - Street 1:997 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9375
Practice Address - Country:US
Practice Address - Phone:989-732-2225
Practice Address - Fax:989-731-6776
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISC008123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4259114Medicaid
MIU81378Medicare UPIN
MI0N15800Medicare ID - Type Unspecified