Healthcare Provider Details

I. General information

NPI: 1639537913
Provider Name (Legal Business Name): SHANNON KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 GRAND RIVER AVE
DETROIT MI
48208-2962
US

IV. Provider business mailing address

3111 GRAND RIVER AVE
DETROIT MI
48208-2962
US

V. Phone/Fax

Practice location:
  • Phone: 313-557-8669
  • Fax:
Mailing address:
  • Phone: 313-557-8669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: