Provider Demographics
NPI:1881241586
Name:TASSAVA, SHANNON MAURA (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MAURA
Last Name:TASSAVA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3237
Mailing Address - Country:US
Mailing Address - Phone:507-581-4702
Mailing Address - Fax:
Practice Address - Street 1:1716 SUNSET DR
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3237
Practice Address - Country:US
Practice Address - Phone:507-581-4702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4343103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical