MEDICARE: SHANNON HIMANGO L.M.F.T.

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	106H00000X	Marriage & Family Therapist	1574	MN

General Provider Information

NPI Number	:	1528438421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON HIMANGO L.M.F.T.

Provider Business Mailing Address
First Line	:	1804 W 50TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1001
Country	:	US
Telephone Number	:	612-927-7335
Fax Number	:	612-927-4259

Provider Business Practice Location Address
First Line	:	1804 W 50TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1001
Country	:	US
Telephone Number	:	612-927-7335
Fax Number	:	612-927-4259

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

Provider Enumeration Date	:	10/05/2015
Last Update Date	:	10/05/2015

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