Provider Demographics
NPI:1538649595
Name:THOMAS-SHANOBI, PETRONELLAH THOKO (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:PETRONELLAH
Middle Name:THOKO
Last Name:THOMAS-SHANOBI
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 FREEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1751
Mailing Address - Country:US
Mailing Address - Phone:763-438-5529
Mailing Address - Fax:
Practice Address - Street 1:2800 FREEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-1751
Practice Address - Country:US
Practice Address - Phone:763-438-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1891101YM0800X
MNCC01891101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN000000OtherBEHAVIORAL HEALTH