Provider Demographics
NPI:1134924236
Name:SHANNON, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 SUFFIELD WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-5884
Mailing Address - Country:US
Mailing Address - Phone:269-303-4803
Mailing Address - Fax:
Practice Address - Street 1:6070 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9234
Practice Address - Country:US
Practice Address - Phone:269-409-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-13
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851119519101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor