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General NPI Number Information
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NPI Number | 1295855963
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Entity Type | Individual
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Provider Name | SHAWN S. GRAVELLE LPCC
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Gender | Male
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 07/22/2024
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Provider Practice Location Address
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Address Line | 1107 HAZELTINE BLVD STE 370
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City | CHASKA
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State | MN
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Zip | 55318-1009
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Country | US
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Telephone | 952-395-1441
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Fax | 651-395-1442
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Provider Business Mailing Address
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Address Line | 1900 SILVER LAKE RD NW STE 110
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City | NEW BRIGHTON
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State | MN
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Zip | 55112-1789
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Country | US
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Telephone | 651-628-9566
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Fax | 651-628-0411
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LPC3523
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1217
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License Number State | MN
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