Provider Demographics
NPI:1073927968
Name:GRANT, SHELLY (LICSW)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17858 COBBLESTONE WAY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-2140
Mailing Address - Country:US
Mailing Address - Phone:612-327-8326
Mailing Address - Fax:952-545-0098
Practice Address - Street 1:715 FLORIDA AVE S STE 307
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1759
Practice Address - Country:US
Practice Address - Phone:952-544-6808
Practice Address - Fax:952-545-0098
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN195931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical