Kelly Jean Tibbetts, LICSW
Individual provider Active NPI Clinical Social Worker · Spring Park, MN
NPI 1992350367 · NPPES record last updated Jun 6, 2025
Key facts
- NPI
- 1992350367
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Social Worker 1041C0700X
- License
- 22636 (MN)
- Practice address
- 4154 Shoreline Dr Ste 202
Spring Park, MN 55384-5610 - Phone
- (952) 491-9450
- NPI assigned
- Aug 2, 2019
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 3
Medicare Care Compare profile
- Specialty
- Clinical Social Worker
- Education
- Other, 2016
- Medicare assignment
- May accept Medicare assignment
- Group practices
- Restorative Behavioral Health Services
Practice addresses (Care Compare)
101 Main St S
Suite 102
Hutchinson, MN 55350-2555
Phone (763) 222-7191
1890 County Rd
Suite 4
Carlton, MN 55718-8166
Phone (218) 409-7508
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20251231000701 | MN | Practitioner - Clinical Social Worker | 7911493861 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 22636 | MN | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mindfully Healing Inc. | Current |
Accepting new patients | |
| Northwoods Counseling, LLC | Current |
Accepting new patients |
Locations
4154 Shoreline Dr
Ste 202
Spring Park, MN 55384
Phone (612) 562-9880
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 22636 | MN | Yes |
Addresses
Primary practice location
4154 Shoreline Dr Ste 202
Spring Park, MN 55384-5610
Mailing address
PO Box 13
Wrenshall, MN 55797-0013
Phone (218) 409-7508
Other practice location 1
7501 80th St S
Cottage Grove, MN 55016-3020
Phone (218) 409-7508
Other providers in Spring Park, MN
- Seniors Care Services LLC
- SP Services
- SP Services
- Thomas G Stocks
- TCM Wellness Clinic
- Mary Moe Trites
- Aaron Tsay
- Urology Associates, LTD.
- Dantel Weaver
- Benedict J Weinbeck III
All providers in Spring Park, MN · Clinical Social Worker in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 6, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.