Healthcare Provider Details

I. General information

NPI: 1437749702
Provider Name (Legal Business Name): SHIFT LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

IV. Provider business mailing address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

V. Phone/Fax

Practice location:
  • Phone: 612-562-6605
  • Fax:
Mailing address:
  • Phone: 612-562-6605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JANNA MARIE MASON
Title or Position: OWNER, LPCC
Credential: MS, LPCC, NCC
Phone: 612-562-6605