Healthcare Provider Details

I. General information

NPI: 1104376250
Provider Name (Legal Business Name): SHANNON ROEHM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 07/04/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W RUSSELL ST
SALINE MI
48176-1183
US

IV. Provider business mailing address

400 W RUSSELL ST
SALINE MI
48176-1183
US

V. Phone/Fax

Practice location:
  • Phone: 734-429-1660
  • Fax: 734-429-0023
Mailing address:
  • Phone: 734-429-1660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801118677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: