1366874299 NPI number — JEFF SHIVELY, MSW, LICSW

Table of content: (NPI 1366874299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366874299 NPI number — JEFF SHIVELY, MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFF SHIVELY, MSW, LICSW
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366874299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12805 HIGHWAY 55
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55441-3880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-723-0408
Provider Business Mailing Address Fax Number:
763-210-5379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12805 HIGHWAY 55
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55441-3880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-723-0408
Provider Business Practice Location Address Fax Number:
763-210-5379
Provider Enumeration Date:
08/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SHIVELY
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
612-723-0408

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  18053 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com