Healthcare Provider Details

I. General information

NPI: 1629964515
Provider Name (Legal Business Name): MRS. SHANNON MICHAEL MERHOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5815 BROADWAY AVE
GREAT BEND KS
67530-3197
US

IV. Provider business mailing address

5815 BROADWAY AVE
GREAT BEND KS
67530-3197
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2544
  • Fax:
Mailing address:
  • Phone: 620-792-2544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number03435-T
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: