Provider Demographics
NPI:1629165626
Name:REARDON, SHIRLEY (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 COLLEEN LN
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8325
Mailing Address - Country:US
Mailing Address - Phone:810-667-0500
Mailing Address - Fax:
Practice Address - Street 1:1570 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1154
Practice Address - Country:US
Practice Address - Phone:810-667-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802072472104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1705242 TYPE 21Medicaid