MEDICARE: SHAWN ELIZABETH LARRY MSW

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	1041C0700X	Clinical Social Worker	6801093123	MI

General Provider Information

NPI Number	:	1902147101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN ELIZABETH LARRY MSW

Provider Business Mailing Address
First Line	:	3465 S STATE RD
Second Line	:
City	:	ITHACA
State	:	MI
Zip	:	48847-9678
Country	:	US
Telephone Number	:	989-750-1848
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 S MISSION ST STE 7
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-3939
Country	:	US
Telephone Number	:	989-750-1848
Fax Number	:

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

Provider Enumeration Date	:	03/13/2013
Last Update Date	:	03/13/2013

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