Provider Demographics
NPI:1578590568
Name:GREEN, SHELLY ELAINE (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:ELAINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7757 LAMONT AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4066
Mailing Address - Country:US
Mailing Address - Phone:612-616-8401
Mailing Address - Fax:
Practice Address - Street 1:7757 LAMONT AVE NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55301-4066
Practice Address - Country:US
Practice Address - Phone:612-616-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16068104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN261943100Medicaid
922241046607OtherPREFERRED ONE
MN800001610Medicare ID - Type Unspecified