Healthcare Provider Details

I. General information

NPI: 1114459591
Provider Name (Legal Business Name): SHANNON COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 S MILFORD RD
HIGHLAND MI
48357-4938
US

IV. Provider business mailing address

2871 SANDHURST
ROCHESTER HILLS MI
48307-4556
US

V. Phone/Fax

Practice location:
  • Phone: 248-684-9610
  • Fax:
Mailing address:
  • Phone: 248-720-8201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101005309
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: