Provider Demographics
NPI:1902147101
Name:LARRY, SHAWN ELIZABETH (MSW)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:ELIZABETH
Last Name:LARRY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-9678
Mailing Address - Country:US
Mailing Address - Phone:989-750-1848
Mailing Address - Fax:
Practice Address - Street 1:1205 S MISSION ST STE 7
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3939
Practice Address - Country:US
Practice Address - Phone:989-750-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010931231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty