MEDICARE: SHANTI COUNSELING SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	6801067098	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1235158627	OTHER	MI	NPI
2	8008976950	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1174706048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANTI COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	6199 MILLER RD
Second Line	:	SUITE A
City	:	SWARTZ CREEK
State	:	MI
Zip	:	48473-1585
Country	:	US
Telephone Number	:	810-630-0904
Fax Number	:

Provider Business Practice Location Address
First Line	:	6199 MILLER RD
Second Line	:	SUITE A
City	:	SWARTZ CREEK
State	:	MI
Zip	:	48473-1585
Country	:	US
Telephone Number	:	810-630-0904
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THERESA MARIE CALLARD-MOORE
Credential	:	MSW, ACSW, LMSW
Telephone Number	:	810-630-0904

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	12/13/2007

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Directions to “SHANTI COUNSELING SERVICES, LLC ” Practice Location

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