Provider Demographics
NPI:1558841320
Name:SHAFFER, SHELLEY A (MS, LPCC)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:A
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-0463
Mailing Address - Country:US
Mailing Address - Phone:218-380-0175
Mailing Address - Fax:
Practice Address - Street 1:34079 LAKETOWN RD STE 4
Practice Address - Street 2:
Practice Address - City:STURGEON LAKE
Practice Address - State:MN
Practice Address - Zip Code:55783-5006
Practice Address - Country:US
Practice Address - Phone:218-380-0175
Practice Address - Fax:218-485-9105
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN651101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional