Provider Demographics
NPI:1295855963
Name:GRAVELLE, SHAWN S (LPCC)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:S
Last Name:GRAVELLE
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1107 HAZELTINE BLVD STE 370
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1009
Practice Address - Country:US
Practice Address - Phone:952-395-1441
Practice Address - Fax:651-395-1442
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC3523101Y00000X
MN1217101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor