Provider Demographics
NPI:1407185077
Name:MCSHANE, TIMOTHY W (MA, LPC, CAACD, NCC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:MCSHANE
Suffix:
Gender:M
Credentials:MA, LPC, CAACD, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4702
Mailing Address - Country:US
Mailing Address - Phone:616-456-6135
Mailing Address - Fax:616-771-9779
Practice Address - Street 1:516 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4702
Practice Address - Country:US
Practice Address - Phone:616-456-6135
Practice Address - Fax:231-347-9313
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010843101YP2500X
1041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical