Healthcare Provider Details

I. General information

NPI: 1639032345
Provider Name (Legal Business Name): SHELBY BOOM LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29877 TELEGRAPH RD STE 400
SOUTHFIELD MI
48034-7661
US

IV. Provider business mailing address

29877 TELEGRAPH RD STE 400
SOUTHFIELD MI
48034-7661
US

V. Phone/Fax

Practice location:
  • Phone: 248-294-0539
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6851121040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: