Provider Demographics
NPI:1508464561
Name:BOOKWALTER, SHANNON (LADC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BOOKWALTER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6058 HIGHWAY 10 NW
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4530
Mailing Address - Country:US
Mailing Address - Phone:763-421-5590
Mailing Address - Fax:
Practice Address - Street 1:6058 HIGHWAY 10 NW
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-4530
Practice Address - Country:US
Practice Address - Phone:763-421-5590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304535101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)