Provider Demographics
NPI:1992350367
Name:TIBBETTS, KELLY JEAN (LICSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:TIBBETTS
Suffix:
Gender:F
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:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:WRENSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:55797-0013
Mailing Address - Country:US
Mailing Address - Phone:218-409-7508
Mailing Address - Fax:
Practice Address - Street 1:4154 SHORELINE DR STE 202
Practice Address - Street 2:
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-5610
Practice Address - Country:US
Practice Address - Phone:952-491-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical