Provider Demographics
NPI:1518490564
Name:RIDDLE, SHENA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:SHENA
Middle Name:MARIE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 CONSTITUTION BLVD
Mailing Address - Street 2:APT 2
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-3855
Mailing Address - Country:US
Mailing Address - Phone:248-613-4647
Mailing Address - Fax:
Practice Address - Street 1:11270 E 13 MILE RD
Practice Address - Street 2:STE 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2599
Practice Address - Country:US
Practice Address - Phone:586-738-9320
Practice Address - Fax:586-751-3201
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011065261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical