Healthcare Provider Details

I. General information

NPI: 1104531458
Provider Name (Legal Business Name): SHANNON MARTINA RAPALO MEDINA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5404 N LOVERS LANE RD STE 10
MILWAUKEE WI
53225-3006
US

IV. Provider business mailing address

5404 N LOVERS LANE RD STE 10
MILWAUKEE WI
53225-3006
US

V. Phone/Fax

Practice location:
  • Phone: 218-332-4771
  • Fax:
Mailing address:
  • Phone: 218-332-4771
  • Fax: 612-486-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26538
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: