Healthcare Provider Details

I. General information

NPI: 1831153550
Provider Name (Legal Business Name): SHANNA D MATHESON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNA D SHEMWELL LMSW

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MICHIGAN ST NE SUITE 3100
GRAND RAPIDS MI
49503-2562
US

IV. Provider business mailing address

710 KENMOOR AVE SE SUITE 100
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-9800
  • Fax: 616-954-2116
Mailing address:
  • Phone: 616-954-9800
  • Fax: 616-954-4444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801059166
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: