Healthcare Provider Details

I. General information

NPI: 1558279729
Provider Name (Legal Business Name): SHANNON VANWASHENOVA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S RAISINVILLE RD
MONROE MI
48161-9047
US

IV. Provider business mailing address

6535 NEWPORT SOUTH RD
NEWPORT MI
48166-9625
US

V. Phone/Fax

Practice location:
  • Phone: 734-322-2700
  • Fax:
Mailing address:
  • Phone: 734-735-0262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801116769
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801116769
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: