Provider Demographics
NPI:1104298207
Name:NYANANKPE, SHANAE (MA)
Entity type:Individual
Prefix:
First Name:SHANAE
Middle Name:
Last Name:NYANANKPE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SHANAE
Other - Middle Name:
Other - Last Name:NYANANKPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18640 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-7700
Practice Address - Country:US
Practice Address - Phone:313-744-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007832103TC0700X
101YM0800X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health