Basic Information
| Provider Information | |||||||||
| NPI: | 1144729930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUALLEY | ||||||||
| OtherFirstName: | SHANNA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2405 8TH ST S STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565604200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183314866 | ||||||||
| FaxNumber: | 2183314867 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 8TH ST S STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565604200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183314866 | ||||||||
| FaxNumber: | 2183314867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2018 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | ND | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 2866 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.