Provider Demographics
NPI:1205223377
Name:BOOMGAARD, SHAWNA L (LMSW)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:L
Last Name:BOOMGAARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:L
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3694 CLARKSTON RD STE D
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-5213
Mailing Address - Country:US
Mailing Address - Phone:248-390-4191
Mailing Address - Fax:
Practice Address - Street 1:3694 CLARKSTON RD STE D
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-5213
Practice Address - Country:US
Practice Address - Phone:248-390-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010865241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical