Provider Demographics
NPI:1063052009
Name:TAVIS, SHANNON (LMSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TAVIS
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 1:36800 WOODWARD AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0915
Mailing Address - Country:US
Mailing Address - Phone:248-457-5178
Mailing Address - Fax:248-792-9234
Practice Address - Street 1:36800 WOODWARD AVE STE 320
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0915
Practice Address - Country:US
Practice Address - Phone:248-325-8642
Practice Address - Fax:248-792-9234
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011062201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical