Provider Demographics
NPI:1376321729
Name:KNUTSON, SHANNA MARIE (EDS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:MARIE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:MS
Other - First Name:SHANNA
Other - Middle Name:M
Other - Last Name:FLICEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5912 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-0818
Mailing Address - Country:US
Mailing Address - Phone:507-440-2816
Mailing Address - Fax:
Practice Address - Street 1:201 E 38TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5815
Practice Address - Country:US
Practice Address - Phone:605-367-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN424713103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool