Healthcare Provider Details

I. General information

NPI: 1548629637
Provider Name (Legal Business Name): SHANNON BRUIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 MADISON AVE SE
GRAND RAPIDS MI
49507-1715
US

IV. Provider business mailing address

901 EASTERN AVE NE
GRAND RAPIDS MI
49503-1201
US

V. Phone/Fax

Practice location:
  • Phone: 616-893-8025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL770724
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: