Provider Demographics
NPI:1871862375
Name:SHANNON, DAVID EDWARD (MSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11236 494TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMBOY
Mailing Address - State:MN
Mailing Address - Zip Code:56010-4414
Mailing Address - Country:US
Mailing Address - Phone:507-399-3789
Mailing Address - Fax:
Practice Address - Street 1:2324 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1843
Practice Address - Country:US
Practice Address - Phone:507-399-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN133971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical