Provider Demographics
NPI:1720326440
Name:SHANE, BRENDAN C (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:C
Last Name:SHANE
Suffix:
Gender:M
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 1:6513 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:952-983-0216
Mailing Address - Fax:
Practice Address - Street 1:7575 GOLDEN VALLEY RD
Practice Address - Street 2:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN131921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical