Provider Demographics
NPI:1326324369
Name:SHALLOW, KATHRYN ANN (LLPC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:SHALLOW
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:SUITE 2070
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2184
Mailing Address - Country:US
Mailing Address - Phone:248-436-6202
Mailing Address - Fax:
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE 2070
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-436-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional