Provider Demographics
NPI:1326655093
Name:HAMP, SHANE MICHAEL (LICSW)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:HAMP
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 NORFOLK AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-3056
Mailing Address - Country:US
Mailing Address - Phone:651-365-8298
Mailing Address - Fax:
Practice Address - Street 1:1000 RADIO DR STE 210
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-8444
Practice Address - Country:US
Practice Address - Phone:651-365-8298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN273781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical