Provider Demographics
NPI:1427375609
Name:POWERS, SHANNON MARGARET
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARGARET
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29972 RICHLAND ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3044
Mailing Address - Country:US
Mailing Address - Phone:734-673-2864
Mailing Address - Fax:
Practice Address - Street 1:35514 INDIGO DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4946
Practice Address - Country:US
Practice Address - Phone:586-212-2671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI620765586744225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist