Provider Demographics
NPI:1548302276
Name:SHANNON-MYER, MARY C
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:SHANNON-MYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 LITTLE CANADA RD E
Mailing Address - Street 2:#133
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 COUNTY ROAD 10
Practice Address - Street 2:#400
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3072
Practice Address - Country:US
Practice Address - Phone:612-596-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN053181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical