Healthcare Provider Details

I. General information

NPI: 1467856179
Provider Name (Legal Business Name): SHANNON LYNN OLIVER BS, LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER PLACE DR SUITE 250
DETROIT MI
48207-4274
US

IV. Provider business mailing address

25099 PAMELA ST
TAYLOR MI
48180-4523
US

V. Phone/Fax

Practice location:
  • Phone: 313-871-2337
  • Fax: 313-871-1805
Mailing address:
  • Phone: 734-250-2546
  • Fax: 313-871-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802085005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: