Provider Demographics
NPI:1134525769
Name:ROUSH, SHANNON (MA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:ROUSH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N CENTER DR NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8215
Mailing Address - Country:US
Mailing Address - Phone:616-647-2590
Mailing Address - Fax:616-647-2689
Practice Address - Street 1:721 N CENTER DR NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-8215
Practice Address - Country:US
Practice Address - Phone:616-647-2590
Practice Address - Fax:616-647-2689
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK514359171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator