Healthcare Provider Details

I. General information

NPI: 1366685141
Provider Name (Legal Business Name): SHANNON CONNELL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 W 8TH ST STE 200
HOLLAND MI
49423-2702
US

IV. Provider business mailing address

36 W 8TH ST STE 200
HOLLAND MI
49423-2702
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-4846
  • Fax: 616-396-4846
Mailing address:
  • Phone: 166-396-4846
  • Fax: 616-396-4846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301013914
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301018872
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013914
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013914
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301013914
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: