Provider Demographics
NPI:1366840324
Name:BRENDAN SHANE
Entity Type:Organization
Organization Name:BRENDAN SHANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHANE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:952-334-9390
Mailing Address - Street 1:6513 CREEK DR
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-1207
Mailing Address - Country:US
Mailing Address - Phone:952-334-9390
Mailing Address - Fax:
Practice Address - Street 1:7575 GOLDEN VALLEY RD
Practice Address - Street 2:SUITE 370
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4562
Practice Address - Country:US
Practice Address - Phone:952-334-9390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN131921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty