Provider Demographics
NPI:1831153550
Name:MATHESON, SHANNA D (LMSW)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:D
Last Name:MATHESON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:D
Other - Last Name:SHEMWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:710 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2379
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:616-954-4444
Practice Address - Street 1:145 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2562
Practice Address - Country:US
Practice Address - Phone:616-954-9800
Practice Address - Fax:616-954-2116
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010591661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM08620016Medicare PIN