Healthcare Provider Details

I. General information

NPI: 1487571956
Provider Name (Legal Business Name): ANNA SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4467 CASCADE RD SE STE 4480
GRAND RAPIDS MI
49546-3776
US

IV. Provider business mailing address

4467 CASCADE RD SE STE 4480
GRAND RAPIDS MI
49546-3776
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-3784
  • Fax:
Mailing address:
  • Phone: 616-481-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851121530
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: