Provider Demographics
NPI:1477984920
Name:SHADOW, CHRISTI LYNN (LSW)
Entity Type:Individual
Prefix:
First Name:CHRISTI
Middle Name:LYNN
Last Name:SHADOW
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 COOPER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-1512
Mailing Address - Country:US
Mailing Address - Phone:701-352-5129
Mailing Address - Fax:701-352-5060
Practice Address - Street 1:516 COOPER AVE FL 2
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237-1512
Practice Address - Country:US
Practice Address - Phone:701-352-5129
Practice Address - Fax:701-352-5060
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3689104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND79192Medicaid