Provider Demographics
NPI:1871805614
Name:WESSEL, BRITT NICOLE SHACKELFORD (PSYD, LP)
Entity type:Individual
Prefix:
First Name:BRITT
Middle Name:NICOLE SHACKELFORD
Last Name:WESSEL
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:3503 HIGH POINT DRIVE N
Mailing Address - Street 2:BLDG 3, SUITE 230
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6158
Mailing Address - Country:US
Mailing Address - Phone:612-787-7050
Mailing Address - Fax:612-844-2784
Practice Address - Street 1:3503 HIGH POINT DRIVE N
Practice Address - Street 2:BLDG 3, SUITE 230
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6158
Practice Address - Country:US
Practice Address - Phone:612-787-7050
Practice Address - Fax:612-844-2784
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5297103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301108000Medicaid