Provider Demographics
NPI:1578589511
Name:POWELL, SHANNON E (MA LICSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:E
Last Name:POWELL
Suffix:
Gender:F
Credentials:MA LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 GALTIER ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-636-1246
Mailing Address - Fax:
Practice Address - Street 1:2445 GALTIER ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-636-1246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
6251120OtherUNITED BEHAVORIAL HEALTH
30866OtherHEALTH PARTNERS