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General NPI Number Information
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NPI Number | 1063052009
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Entity Type | Individual
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Provider Name | SHANNON TAVIS LMSW
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Gender | Female
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Dates
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Enumeration Date | 01/07/2020
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Last Update Date | 07/22/2021
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Provider Practice Location Address
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Address Line | 36800 WOODWARD AVE STE 320
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48304-0915
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Country | US
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Telephone | 248-325-8642
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Fax | 248-792-9234
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Provider Business Mailing Address
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Address Line | 36800 WOODWARD AVE STE 320
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48304-0915
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Country | US
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Telephone | 248-457-5178
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Fax | 248-792-9234
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801106220
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License Number State | MI
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