Provider Demographics
NPI:1376782961
Name:SHIVELY, JEFF WILLIAM (LICSW)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:WILLIAM
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12805 HIGHWAY 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3859
Mailing Address - Country:US
Mailing Address - Phone:612-723-0408
Mailing Address - Fax:763-210-5379
Practice Address - Street 1:12805 HIGHWAY 55
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3859
Practice Address - Country:US
Practice Address - Phone:612-723-0408
Practice Address - Fax:763-210-5379
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical