Provider Demographics
NPI:1609055714
Name:SHANNON, R. TIMOTHY (LLPC)
Entity Type:Individual
Prefix:MR
First Name:R.
Middle Name:TIMOTHY
Last Name:SHANNON
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 W CROSS ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2103
Mailing Address - Country:US
Mailing Address - Phone:734-649-9989
Mailing Address - Fax:
Practice Address - Street 1:1012 W CROSS ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2103
Practice Address - Country:US
Practice Address - Phone:734-649-9989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010082101YA0400X
MI101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral