Healthcare Provider Details

I. General information

NPI: 1275147266
Provider Name (Legal Business Name): SHELLEY ANN SHAFFER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2020
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 ARROWHEAD LN
MOOSE LAKE MN
55767-7707
US

IV. Provider business mailing address

PO BOX 463
MOOSE LAKE MN
55767-0463
US

V. Phone/Fax

Practice location:
  • Phone: 218-380-0175
  • Fax: 218-485-9105
Mailing address:
  • Phone: 218-380-0175
  • Fax: 218-485-9105

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHELLEY A SHAFFER
Title or Position: OWNER
Credential:
Phone: 218-380-0175