Provider Demographics
NPI:1275949299
Name:SWARTHOUT, SHANNON (LADC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SWARTHOUT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 SKILLMAN AVE E APT 104
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2168
Mailing Address - Country:US
Mailing Address - Phone:612-454-2321
Mailing Address - Fax:651-489-6458
Practice Address - Street 1:135 COLORADO ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2244
Practice Address - Country:US
Practice Address - Phone:612-454-2131
Practice Address - Fax:651-489-6458
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303820324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility