Provider Demographics
NPI:1669036406
Name:SHANNON-TAMRAT, SELAMAWIT ELIZABETH
Entity Type:Individual
Prefix:
First Name:SELAMAWIT
Middle Name:ELIZABETH
Last Name:SHANNON-TAMRAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5775 WAYZATA BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1233
Mailing Address - Country:US
Mailing Address - Phone:763-312-1878
Mailing Address - Fax:
Practice Address - Street 1:5775 WAYZATA BLVD STE 700
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1233
Practice Address - Country:US
Practice Address - Phone:763-312-1878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MNSTUDENT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN47-40144022Medicaid