Provider Demographics
NPI:1306337431
Name:SHELLY SYMONS, LLC
Entity type:Organization
Organization Name:SHELLY SYMONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SYMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:218-343-7548
Mailing Address - Street 1:312 N CENTRAL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2546
Mailing Address - Country:US
Mailing Address - Phone:218-464-1759
Mailing Address - Fax:
Practice Address - Street 1:312 N CENTRAL AVE STE 500
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2546
Practice Address - Country:US
Practice Address - Phone:218-464-1759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1017668300021261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)