Provider Demographics
NPI:1265539308
Name:BERVEN, SHELLEY SEARS (MSW)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:SEARS
Last Name:BERVEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2273 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1904
Mailing Address - Country:US
Mailing Address - Phone:651-293-3923
Mailing Address - Fax:651-642-5909
Practice Address - Street 1:790 CLEVELAND AVE S STE 207
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-3866
Practice Address - Country:US
Practice Address - Phone:651-224-3035
Practice Address - Fax:651-690-0968
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN068451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN735820200Medicaid
MN172678OtherUCARE