Provider Demographics
NPI:1457324030
Name:ENGDAHL, SHARON A (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:ENGDAHL
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:6150 OREN AVE N
Practice Address - Street 2:MAIL CODE 14001A
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6173
Practice Address - Country:US
Practice Address - Phone:651-430-1868
Practice Address - Fax:651-430-0177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN96221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R13659Medicare UPIN