Provider Demographics
NPI:1295444685
Name:BANKEN, SHELBY R (MA, LADC)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:R
Last Name:BANKEN
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:R
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13603 80TH CIR N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8961
Mailing Address - Country:US
Mailing Address - Phone:763-274-3120
Mailing Address - Fax:
Practice Address - Street 1:13603 80TH CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8961
Practice Address - Country:US
Practice Address - Phone:763-274-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305153101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)