Provider Demographics
NPI:1447788476
Name:KOCH, SHANNON M (MS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:KOCH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3884 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 N MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1370
Practice Address - Country:US
Practice Address - Phone:734-433-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-04
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017089103T00000X
MI6301017098103T00000X
MI6361007528103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist