Provider Demographics
NPI:1922608256
Name:ROSE, SHANA-KAY SHANTELL
Entity Type:Individual
Prefix:
First Name:SHANA-KAY
Middle Name:SHANTELL
Last Name:ROSE
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 1:8660 OLD CEDAR AVE S APT 211
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2028
Mailing Address - Country:US
Mailing Address - Phone:754-332-6318
Mailing Address - Fax:
Practice Address - Street 1:4201 DEAN LAKES BLVD STE 160
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2863
Practice Address - Country:US
Practice Address - Phone:612-509-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1588993091Medicaid