Provider Demographics
NPI:1760817399
Name:THAYER, SHANNON (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THAYER
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 COLONY DR
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1096
Mailing Address - Country:US
Mailing Address - Phone:734-646-9985
Mailing Address - Fax:
Practice Address - Street 1:2350 WASHTENAW AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4532
Practice Address - Country:US
Practice Address - Phone:734-956-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional