Provider Demographics
NPI:1528512274
Name:SHALEEN, AMY PENAL (LICSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:PENAL
Last Name:SHALEEN
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 1:11725 STINSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-9542
Mailing Address - Country:US
Mailing Address - Phone:651-257-7806
Mailing Address - Fax:651-257-8852
Practice Address - Street 1:11725 STINSON AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9542
Practice Address - Country:US
Practice Address - Phone:651-257-7806
Practice Address - Fax:651-257-8852
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN164821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical