Provider Demographics
NPI:1023406253
Name:SHEDLOCK, MEGAN JEAN BOOM
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:JEAN BOOM
Last Name:SHEDLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 CENTERVILLE RD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3699
Mailing Address - Country:US
Mailing Address - Phone:651-289-9385
Mailing Address - Fax:651-289-3113
Practice Address - Street 1:4444 CENTERVILLE RD
Practice Address - Street 2:SUITE 235
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-3699
Practice Address - Country:US
Practice Address - Phone:651-289-9385
Practice Address - Fax:651-289-3113
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist