Provider Demographics
NPI:1437522935
Name:KANNAN, SHUBHRA
Entity Type:Individual
Prefix:
First Name:SHUBHRA
Middle Name:
Last Name:KANNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHUBHRA
Other - Middle Name:
Other - Last Name:SINHA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:4405 HERITAGE AVE
Mailing Address - Street 2:APT B5
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4405 HERITAGE AVE
Practice Address - Street 2:APT B5
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:414-255-7795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist