Provider Demographics
NPI:1356425904
Name:SHEA, MICHAEL J (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:SHEA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 CLIFTON PL STE 111
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3242
Mailing Address - Country:US
Mailing Address - Phone:612-871-2165
Mailing Address - Fax:612-871-2448
Practice Address - Street 1:1730 CLIFTON PL STE 111
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3242
Practice Address - Country:US
Practice Address - Phone:612-871-2165
Practice Address - Fax:612-871-2448
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2029103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55676SHOtherBLUE CROSS PROVIDER
MNLP 2029MNOtherLICENCED PSYCHOLOGIST
MN421047600Medicaid
MNLP 2029MNOtherLICENCED PSYCHOLOGIST