Provider Demographics
NPI:1851644199
Name:WILLIAMS, SHANNA (PSYD)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6195 MILLER RD
Mailing Address - Street 2:STE A
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473
Mailing Address - Country:US
Mailing Address - Phone:810-630-1152
Mailing Address - Fax:810-630-9107
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018846103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301018846OtherLICENSE NUMBER