Healthcare Provider Details

I. General information

NPI: 1366874299
Provider Name (Legal Business Name): JEFF SHIVELY, MSW, LICSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 PENN AVE S STE 500E
BLOOMINGTON MN
55431-1367
US

IV. Provider business mailing address

8120 PENN AVE S STE 500E
BLOOMINGTON MN
55431-1367
US

V. Phone/Fax

Practice location:
  • Phone: 612-723-0408
  • Fax:
Mailing address:
  • Phone: 612-723-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18053
License Number StateMN

VIII. Authorized Official

Name: MR. JEFF W SHIVELY
Title or Position: PRESIDENT
Credential: LICSW
Phone: 612-723-0408