Provider Demographics
NPI:1720471832
Name:MARTIN, SHAWNA (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 12TH ST E
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-2336
Mailing Address - Country:US
Mailing Address - Phone:952-361-9700
Mailing Address - Fax:320-864-6130
Practice Address - Street 1:925 12TH ST E
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2336
Practice Address - Country:US
Practice Address - Phone:952-361-9700
Practice Address - Fax:320-864-6130
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2677106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist