Healthcare Provider Details

I. General information

NPI: 1770099731
Provider Name (Legal Business Name): SHAWNA MARIE BURNHAM LSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 1ST ST W
BEMIDJI MN
56601-4002
US

IV. Provider business mailing address

112 1ST ST W
BEMIDJI MN
56601-4002
US

V. Phone/Fax

Practice location:
  • Phone: 218-888-8032
  • Fax: 218-308-6438
Mailing address:
  • Phone: 218-888-8032
  • Fax: 218-308-6438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304730
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: