Basic Information
| Provider Information | |||||||||
| NPI: | 1851918593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | SHANA | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | MSW, LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 EAST 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2183028698 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | TWO HARBORS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 556161300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188345520 | ||||||||
| FaxNumber: | 2188344264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2020 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 26439 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.