Provider Demographics
NPI:1881490621
Name:SMAALADEN, SHANNON RENEE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:SMAALADEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 58TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2821
Mailing Address - Country:US
Mailing Address - Phone:701-213-0726
Mailing Address - Fax:612-446-5798
Practice Address - Street 1:4825 58TH AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-2821
Practice Address - Country:US
Practice Address - Phone:701-213-0726
Practice Address - Fax:612-446-5798
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician