Provider Demographics
NPI:1013404839
Name:SHANNON, EMMA FAYE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:FAYE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:SHIELDS-NORDNESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-0051
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:952-443-4604
Practice Address - Street 1:1502 LONDON RD STE 205
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1788
Practice Address - Country:US
Practice Address - Phone:612-234-4689
Practice Address - Fax:612-234-4689
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN250471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical