Provider Demographics
NPI:1902315096
Name:STANTON, SHANNON KAY (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:STANTON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KAY
Other - Last Name:JUEDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:149 THOMPSON AVE E STE 150
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3238
Practice Address - Country:US
Practice Address - Phone:651-450-0860
Practice Address - Fax:651-450-0759
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6134103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical