Provider Demographics
NPI:1114083029
Name:LANSING, SHIRLEE CORRINE (LICSW)
Entity Type:Individual
Prefix:
First Name:SHIRLEE
Middle Name:CORRINE
Last Name:LANSING
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:16201 90TH ST NE, SUITE 200
Practice Address - Street 2:NYSTROM & ASSOCIATES, LTD.
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-746-9492
Practice Address - Fax:763-746-3685
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN07281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN361219800Medicaid