Provider Demographics
NPI:1821597543
Name:SHOPE, DONALD JR (LADC, CAP)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:SHOPE
Suffix:JR
Gender:M
Credentials:LADC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4496 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2235
Mailing Address - Country:US
Mailing Address - Phone:561-729-8368
Mailing Address - Fax:
Practice Address - Street 1:4496 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2235
Practice Address - Country:US
Practice Address - Phone:561-729-8368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301362101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)