Provider Demographics
NPI:1831387257
Name:DENNIS, SHANNON L (PHD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:DENNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1085 S LINDEN RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3421
Mailing Address - Country:US
Mailing Address - Phone:810-732-6092
Mailing Address - Fax:810-732-2232
Practice Address - Street 1:2700 ROBERT T LONGWAY BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2190
Practice Address - Country:US
Practice Address - Phone:810-239-1975
Practice Address - Fax:810-239-1281
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013086103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical