MEDICARE: SHANNON RENE GORIS LPC

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	101YM0800X	Mental Health Counselor	6401015889	MI
2	101YM0800X	Mental Health Counselor	6401017357	MI
3	101Y00000X	Counselor	6401017357	MI

General Provider Information

NPI Number	:	1285172338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON RENE GORIS LPC

Provider Business Mailing Address
First Line	:	10975 CEDAR ISLAND RD
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48386-2609
Country	:	US
Telephone Number	:	248-840-7792
Fax Number	:

Provider Business Practice Location Address
First Line	:	1460 WALTON BLVD STE 60
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-1729
Country	:	US
Telephone Number	:	248-608-4514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2017
Last Update Date	:	11/03/2023

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