Provider Demographics
NPI:1104531458
Name:RAPALO MEDINA, SHANNON MARTINA (LICSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARTINA
Last Name:RAPALO MEDINA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7850 ZANE AVE N APT 108
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3032
Mailing Address - Country:US
Mailing Address - Phone:612-293-0635
Mailing Address - Fax:
Practice Address - Street 1:5155 E RIVER RD STE 401
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55421-3777
Practice Address - Country:US
Practice Address - Phone:763-913-9184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN265381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical