Basic Information
| Provider Information | |||||||||
| NPI: | 1851644199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | SHANNA | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6195 MILLER RD | ||||||||
| Address2: | STE A | ||||||||
| City: | SWARTZ CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106301152 | ||||||||
| FaxNumber: | 8106309107 | ||||||||
| Practice Location | |||||||||
| Address1: | 8495 CRATER LAKE HWY | ||||||||
| Address2: | |||||||||
| City: | WHITE CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975033011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418262111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301018846 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6301018846 | 01 | MI | LICENSE NUMBER | OTHER |