Provider Demographics
NPI:1366874299
Name:JEFF SHIVELY, MSW, LICSW
Entity type:Organization
Organization Name:JEFF SHIVELY, MSW, LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-723-0408
Mailing Address - Street 1:12805 HIGHWAY 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3880
Mailing Address - Country:US
Mailing Address - Phone:612-723-0408
Mailing Address - Fax:763-210-5379
Practice Address - Street 1:12805 HIGHWAY 55
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3880
Practice Address - Country:US
Practice Address - Phone:612-723-0408
Practice Address - Fax:763-210-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty