Provider Demographics
NPI:1750850988
Name:WEISS, SHANNA (LP)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:WEISS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 AMES CROSSING RD STE 600
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2519
Mailing Address - Country:US
Mailing Address - Phone:651-774-0011
Mailing Address - Fax:651-774-0606
Practice Address - Street 1:1930 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4708
Practice Address - Country:US
Practice Address - Phone:651-774-0011
Practice Address - Fax:651-774-0606
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6149103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical