Provider Demographics
NPI:1588801849
Name:FELL, SHANNON RENEE (CAC-M)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENEE
Last Name:FELL
Suffix:
Gender:F
Credentials:CAC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4290
Mailing Address - Country:US
Mailing Address - Phone:248-674-4630
Mailing Address - Fax:248-674-7157
Practice Address - Street 1:3650 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4290
Practice Address - Country:US
Practice Address - Phone:248-674-4630
Practice Address - Fax:248-674-7157
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI104703101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)