Healthcare Provider Details

I. General information

NPI: 1144472341
Provider Name (Legal Business Name): SHANNON S. WYSINGER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 MOCERI LN
GRAND BLANC MI
48439-4365
US

IV. Provider business mailing address

5360 MOCERI LANE
GRAND BLANC MI
48439-4365
US

V. Phone/Fax

Practice location:
  • Phone: 810-240-1849
  • Fax:
Mailing address:
  • Phone: 810-240-1849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401011056
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401011056
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: