Healthcare Provider Details

I. General information

NPI: 1972282549
Provider Name (Legal Business Name): SHAMELESS THERAPY & CONSULTING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 ROBIN LANE
NEW BRIGHTON MN
55112
US

IV. Provider business mailing address

5115 EXCELSIOR BLVD # 709
ST LOUIS PARK MN
55416-2906
US

V. Phone/Fax

Practice location:
  • Phone: 507-571-2942
  • Fax:
Mailing address:
  • Phone: 507-571-2942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE GOLOB
Title or Position: OWNER
Credential:
Phone: 507-571-2942