Healthcare Provider Details

I. General information

NPI: 1407185077
Provider Name (Legal Business Name): TIMOTHY W MCSHANE MA, LPC, CAACD, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 CHERRY ST SE
GRAND RAPIDS MI
49503-4702
US

IV. Provider business mailing address

516 CHERRY ST SE
GRAND RAPIDS MI
49503-4702
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6135
  • Fax: 231-347-9313
Mailing address:
  • Phone: 616-456-6135
  • Fax: 616-771-9779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010843
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: