Provider Demographics
NPI:1205307659
Name:GOECKE-WATSON, SHANNON MARIE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:GOECKE-WATSON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 JUDICIAL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-7822
Mailing Address - Country:US
Mailing Address - Phone:952-224-8990
Mailing Address - Fax:952-224-8991
Practice Address - Street 1:2970 JUDICIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-7822
Practice Address - Country:US
Practice Address - Phone:952-224-8990
Practice Address - Fax:952-224-8991
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6324103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling