Provider Demographics
NPI:1366685141
Name:CONNELL, SHANNON (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 W 8TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-2702
Mailing Address - Country:US
Mailing Address - Phone:166-396-4846
Mailing Address - Fax:616-396-4846
Practice Address - Street 1:36 W 8TH ST STE 200
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2702
Practice Address - Country:US
Practice Address - Phone:616-396-4846
Practice Address - Fax:616-396-4846
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018872103TC0700X
MI6301013914103TC1900X, 101YM0800X, 103TC0700X
MA6301013914103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912452Medicaid
MI750910513Medicare UPIN
MI750910532Medicare UPIN
MI20378Medicare UPIN
MI20366Medicare UPIN
MI20386Medicare UPIN
MI750910527Medicare UPIN
MI750910517Medicare UPIN
MI750910519Medicare UPIN
MI20351Medicare UPIN
MI750910524Medicare UPIN
MI750910530Medicare UPIN
MIOP22320Medicare PIN