Provider Demographics
NPI:1144472341
Name:WYSINGER, SHANNON S (LPC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:WYSINGER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 MOCERI LANE
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4365
Mailing Address - Country:US
Mailing Address - Phone:810-240-1849
Mailing Address - Fax:
Practice Address - Street 1:5360 MOCERI LN
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-4365
Practice Address - Country:US
Practice Address - Phone:810-240-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011056101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health