Provider Demographics
NPI:1245405323
Name:CHAPUSEAUX, SHANNON MILTIMORE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MILTIMORE
Last Name:CHAPUSEAUX
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:MILTIMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:114 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2244
Mailing Address - Country:US
Mailing Address - Phone:248-858-7766
Mailing Address - Fax:248-858-7201
Practice Address - Street 1:2045 E WEST MAPLE RD
Practice Address - Street 2:SUITE D-407
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-3801
Practice Address - Country:US
Practice Address - Phone:248-624-3811
Practice Address - Fax:248-624-0368
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005891101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid