Basic Information
| Provider Information | |||||||||
| NPI: | 1356602452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | SHAVONN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.A., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27056 ABERDEEN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480763667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857704 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2012 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401011031 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.