Basic Information
| Provider Information | |||||||||
| NPI: | 1386255545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAYLESS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHELPS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1401 EAST 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2183028698 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186245683 | ||||||||
| FaxNumber: | 2186245736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 27225 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.