Provider Demographics
NPI:1568196251
Name:PENROD, SHALY M (LMSW)
Entity type:Individual
Prefix:
First Name:SHALY
Middle Name:M
Last Name:PENROD
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4341 S WESTNEDGE AVE STE 2212
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3287
Mailing Address - Country:US
Mailing Address - Phone:269-588-1441
Mailing Address - Fax:
Practice Address - Street 1:650 TRADE CENTRE WAY STE 140
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-0411
Practice Address - Country:US
Practice Address - Phone:269-492-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011196731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical