Provider Demographics
NPI:1851508840
Name:BAVONESE, SHIRLEY (LMSW, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:
Last Name:BAVONESE
Suffix:
Gender:F
Credentials:LMSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27172 WOODWARD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0963
Mailing Address - Country:US
Mailing Address - Phone:248-546-0407
Mailing Address - Fax:248-548-1925
Practice Address - Street 1:27172 WOODWARD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0963
Practice Address - Country:US
Practice Address - Phone:248-546-0407
Practice Address - Fax:248-548-1925
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010333191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical