Provider Demographics
NPI:1396399002
Name:WIEST, SHAUNA JOLENE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SHAUNA
Middle Name:JOLENE
Last Name:WIEST
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 1:4717 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5625
Mailing Address - Country:US
Mailing Address - Phone:651-470-6052
Mailing Address - Fax:
Practice Address - Street 1:311 RAMSEY ST STE 105
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2323
Practice Address - Country:US
Practice Address - Phone:651-470-6052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN188191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical