Healthcare Provider Details

I. General information

NPI: 1619124716
Provider Name (Legal Business Name): BRENDA SHORES LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 UNIVERSITY AVE W SUITE N 464
SAINT PAUL MN
55104-2801
US

IV. Provider business mailing address

1821 UNIVERSITY AVE W SUITE N 464
SAINT PAUL MN
55104-2801
US

V. Phone/Fax

Practice location:
  • Phone: 651-659-2900
  • Fax: 651-645-7307
Mailing address:
  • Phone: 651-659-2900
  • Fax: 651-645-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: