Healthcare Provider Details

I. General information

NPI: 1144729930
Provider Name (Legal Business Name): SHANNA L GARCIA MS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNA L QUALLEY

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

IV. Provider business mailing address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

V. Phone/Fax

Practice location:
  • Phone: 218-331-4866
  • Fax: 218-331-4867
Mailing address:
  • Phone: 218-331-4866
  • Fax: 218-331-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2866
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: