Provider Demographics
NPI:1104393792
Name:EDMOND, SHAYLA NICOLE (LLMSW)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:NICOLE
Last Name:EDMOND
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N WEST AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2180
Mailing Address - Country:US
Mailing Address - Phone:517-789-1234
Mailing Address - Fax:517-784-7040
Practice Address - Street 1:2002 HOGBACK ROAD
Practice Address - Street 2:SUITE 17
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-956-0051
Practice Address - Fax:888-976-6019
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program