Healthcare Provider Details

I. General information

NPI: 1912196569
Provider Name (Legal Business Name): SHANNON KAY GARRITY PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 UNIVERSITY AVE W 202
SAINT PAUL MN
55114-1769
US

IV. Provider business mailing address

2388 UNIVERSITY AVE W 202
SAINT PAUL MN
55114-1769
US

V. Phone/Fax

Practice location:
  • Phone: 612-703-8589
  • Fax:
Mailing address:
  • Phone: 612-703-8589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number4716
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4716
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4716
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number4716
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number4716
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: