Provider Demographics
NPI:1871077784
Name:SOPER, SHANNON MARIE (LLBSW, LNHA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:SOPER
Suffix:
Gender:F
Credentials:LLBSW, LNHA
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:TREA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1948 S VASSAR RD
Mailing Address - Street 2:
Mailing Address - City:VASSAR
Mailing Address - State:MI
Mailing Address - Zip Code:48768-9710
Mailing Address - Country:US
Mailing Address - Phone:989-325-2996
Mailing Address - Fax:
Practice Address - Street 1:2070 HEMMETER RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3943
Practice Address - Country:US
Practice Address - Phone:800-782-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089182104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty