Provider Demographics
NPI:1750590618
Name:BOMBRYS, SHANA LIN (LMSW)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:LIN
Last Name:BOMBRYS
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 1:780 W LAKE LANSING RD # S6TE200
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8474
Mailing Address - Country:US
Mailing Address - Phone:517-882-6159
Mailing Address - Fax:
Practice Address - Street 1:780 W LAKE LANSING RD # S6TE200
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8474
Practice Address - Country:US
Practice Address - Phone:517-882-6159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI68010884841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801088484OtherLIC. I.D.