Healthcare Provider Details

I. General information

NPI: 1982989414
Provider Name (Legal Business Name): THOMAS HARRISON SHANNON MA, LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2011
Last Update Date: 10/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 DAVISON RD
LAPEER MI
48446-2718
US

IV. Provider business mailing address

5420 DAVISON RD
LAPEER MI
48446-2718
US

V. Phone/Fax

Practice location:
  • Phone: 810-441-8671
  • Fax:
Mailing address:
  • Phone: 810-441-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011160
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: