MEDICARE: SHANNON MARTINA RAPALO MEDINA LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	26538	MN

General Provider Information

NPI Number	:	1104531458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARTINA RAPALO MEDINA LICSW

Provider Business Mailing Address
First Line	:	5404 N LOVERS LANE RD STE 10
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3006
Country	:	US
Telephone Number	:	218-332-4771
Fax Number	:	612-486-7103

Provider Business Practice Location Address
First Line	:	5404 N LOVERS LANE RD STE 10
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3006
Country	:	US
Telephone Number	:	218-332-4771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2023
Last Update Date	:	06/04/2026

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