Basic Information
| Provider Information | |||||||||
| NPI: | 1336543313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALBURG | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLODICH | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3950 S ROCHESTER RD | ||||||||
| Address2: | 1400 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483075160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488446234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3950 S ROCHESTER RD | ||||||||
| Address2: | 1400 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488446234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2014 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401014409 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.