Provider Demographics
NPI:1114584927
Name:MARTIN, SHANNON (LMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7292
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-7292
Mailing Address - Country:US
Mailing Address - Phone:248-920-8660
Mailing Address - Fax:
Practice Address - Street 1:5600 W MAPLE RD STE 302
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3700
Practice Address - Country:US
Practice Address - Phone:248-920-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical