Provider Demographics
NPI:1861857799
Name:PERNELL, SHAWNTEAL NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:SHAWNTEAL
Middle Name:NICOLE
Last Name:PERNELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20529 CHARLTON SQ
Mailing Address - Street 2:201
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 PARKLANE BLVD
Practice Address - Street 2:SUITE 1210E
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2400
Practice Address - Country:US
Practice Address - Phone:313-283-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010903551041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical