Provider Demographics
NPI:1417380007
Name:FROESE, SHANNON (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FROESE
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 1:4705 TOWNE CENTRE RD
Mailing Address - Street 2:MEDICAL ARTS I, SUITE 304
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2818
Mailing Address - Country:US
Mailing Address - Phone:989-921-5100
Mailing Address - Fax:
Practice Address - Street 1:4705 TOWNE CENTRE RD
Practice Address - Street 2:MEDICAL ARTS I, SUITE 304
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2818
Practice Address - Country:US
Practice Address - Phone:989-921-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014080103T00000X, 103TH0004X
WV840103T00000X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth