Provider Demographics
NPI:1053419796
Name:SHANNON, PATRICIA JEAN (PHD, LP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEAN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2619
Mailing Address - Country:US
Mailing Address - Phone:612-825-4407
Mailing Address - Fax:612-825-0768
Practice Address - Street 1:3133 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2620
Practice Address - Country:US
Practice Address - Phone:612-834-7780
Practice Address - Fax:612-624-3744
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4075103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN921813100Medicaid
MN921813100Medicaid