Provider Demographics
NPI:1417476391
Name:HENRY, SHANNON MCCARTNEY (LGSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCCARTNEY
Last Name:HENRY
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 VALLACHER AVE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4933
Mailing Address - Country:US
Mailing Address - Phone:952-818-9004
Mailing Address - Fax:
Practice Address - Street 1:2000 ALDRICH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-3003
Practice Address - Country:US
Practice Address - Phone:612-223-8898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26375104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker