Provider Demographics
NPI:1538404736
Name:BREITKREUTZ, SHANNON (LP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BREITKREUTZ
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LP
Mailing Address - Street 1:21530 201ST ST NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8118
Mailing Address - Country:US
Mailing Address - Phone:763-772-5382
Mailing Address - Fax:
Practice Address - Street 1:107 CEDAR ST
Practice Address - Street 2:SUITE 7
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4504
Practice Address - Country:US
Practice Address - Phone:763-732-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3496103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist