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General NPI Number Information
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NPI Number | 1104531458
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Entity Type | Individual
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Provider Name | SHANNON MARTINA RAPALO MEDINA LICSW
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Gender | Female
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Dates
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Enumeration Date | 01/20/2023
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Last Update Date | 01/20/2023
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Provider Practice Location Address
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Address Line | 5155 E RIVER RD STE 401
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City | FRIDLEY
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State | MN
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Zip | 55421-3777
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Country | US
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Telephone | 763-913-9184
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Fax |
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Provider Business Mailing Address
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Address Line | 7850 ZANE AVE N APT 108
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City | BROOKLYN PARK
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State | MN
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Zip | 55443-3032
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Country | US
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Telephone | 612-293-0635
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 26538
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License Number State | MN
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