MEDICARE: MRS. SHANNON BECKER DOLEZAL MA, ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1578526968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON BECKER DOLEZAL MA, ATC, CSCS

Provider Business Mailing Address
First Line	:	3949 15TH AVE S # 55
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-2742
Country	:	US
Telephone Number	:	706-206-2639
Fax Number	:

Provider Business Practice Location Address
First Line	:	3949 15TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-2742
Country	:	US
Telephone Number	:	706-206-2639
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	07/26/2021

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