Provider Demographics
NPI:1598206161
Name:SHANE, MEGAN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:
Last Name:SHANE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6513 CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439
Mailing Address - Country:US
Mailing Address - Phone:612-418-0299
Mailing Address - Fax:
Practice Address - Street 1:6513 CREEK DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-1207
Practice Address - Country:US
Practice Address - Phone:612-418-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical