Provider Demographics
NPI:1649504127
Name:CARNEY, GAYLE SHANNON (LSW)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:SHANNON
Last Name:CARNEY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4039
Mailing Address - Country:US
Mailing Address - Phone:651-774-0011
Mailing Address - Fax:651-774-0606
Practice Address - Street 1:317 YORK AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4039
Practice Address - Country:US
Practice Address - Phone:651-774-0011
Practice Address - Fax:651-774-0606
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10928171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator