Provider Demographics
NPI:1336543313
Name:MALBURG, SHANNON MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MALBURG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:GLODICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3950 S ROCHESTER RD
Mailing Address - Street 2:1400
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5160
Mailing Address - Country:US
Mailing Address - Phone:248-844-6234
Mailing Address - Fax:
Practice Address - Street 1:3950 S ROCHESTER RD
Practice Address - Street 2:1400
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-844-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional