Provider Demographics
NPI:1790908283
Name:WALKER WORTHEM, SHAWNESE MARIE (MASTERS OF SOCIAL WO)
Entity Type:Individual
Prefix:
First Name:SHAWNESE
Middle Name:MARIE
Last Name:WALKER WORTHEM
Suffix:
Gender:F
Credentials:MASTERS OF SOCIAL WO
Other - Prefix:
Other - First Name:SHAWNESE
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:28475 GREENFIELD RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3034
Mailing Address - Country:US
Mailing Address - Phone:248-424-9778
Mailing Address - Fax:
Practice Address - Street 1:18301 E 8 MILE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3212
Practice Address - Country:US
Practice Address - Phone:586-362-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010570421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800897615OtherBLUE CROSS BLUE SHIELD OF
MI11557119OtherCAQH
MI60001536OtherMAGELLAN
MI0007980763OtherAETNA
MI226708OtherVALUE OPTIONS