Provider Demographics
NPI:1174140644
Name:O'NEILL-SHOBERG, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'NEILL-SHOBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36669 W LYMAN RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3870
Mailing Address - Country:US
Mailing Address - Phone:248-766-1140
Mailing Address - Fax:
Practice Address - Street 1:36669 W LYMAN RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3870
Practice Address - Country:US
Practice Address - Phone:248-766-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010659731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical