Provider Demographics
NPI:1023698099
Name:GRYGO, SHAWN (LADC)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:GRYGO
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 ENERGY PARK DR STE 21
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5248
Mailing Address - Country:US
Mailing Address - Phone:651-252-6070
Mailing Address - Fax:651-252-6071
Practice Address - Street 1:1400 ENERGY PARK DR STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5248
Practice Address - Country:US
Practice Address - Phone:651-252-6070
Practice Address - Fax:651-252-6071
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)