Provider Demographics
NPI:1487704987
Name:KELLY, SHANNON MARY (LMSW)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARY
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 PALMER ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2068
Mailing Address - Country:US
Mailing Address - Phone:734-453-5603
Mailing Address - Fax:734-453-5619
Practice Address - Street 1:42189 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4370
Practice Address - Country:US
Practice Address - Phone:734-453-5603
Practice Address - Fax:734-453-5619
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical