Provider Demographics
NPI:1154590172
Name:LANDAVAZO, SHARON LOUISE (LICSW)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:LOUISE
Last Name:LANDAVAZO
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 1:7300 YORK AVE S APT 104
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4732
Mailing Address - Country:US
Mailing Address - Phone:612-408-2992
Mailing Address - Fax:
Practice Address - Street 1:615 W 35TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4602
Practice Address - Country:US
Practice Address - Phone:612-408-2992
Practice Address - Fax:612-823-8438
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-24
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN67541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical