Provider Demographics
NPI:1356907026
Name:LACKNER, SHANNON G
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:G
Last Name:LACKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6381 OSGOOD AVE N BLDG C
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6118
Mailing Address - Country:US
Mailing Address - Phone:651-560-5275
Mailing Address - Fax:
Practice Address - Street 1:1554 MIDWAY PKWY APT 448
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-2464
Practice Address - Country:US
Practice Address - Phone:218-639-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2993101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1356907026OtherCOMMERCIAL