Basic Information
| Provider Information | |||||||||
| NPI: | 1831387257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCINTOSH | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1085 S LINDEN RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107326092 | ||||||||
| FaxNumber: | 8107322232 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 ROBERT T LONGWAY BLVD | ||||||||
| Address2: | SUITE I | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102391975 | ||||||||
| FaxNumber: | 8102391281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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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 | 103TC0700X | 6301013086 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.