Kelly Jean Tibbetts, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

22636 Issued in MN

Practice address

4154 Shoreline Dr Ste 202
Spring Park, MN 55384-5610

Phone

(952) 491-9450

NPI assigned

Aug 2, 2019

Last updated

Jun 6, 2025By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 2016

Medicare assignment

May accept Medicare assignment

Group practices

Restorative Behavioral Health ServicesGroup PAC ID 3779060751, 3 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Northwoods Counseling, LLC

  • Mental Health Counselor
  • Carlton, MN
  • NPI 1861380172
  Medicare reassignment NPD Authorized official
• Restorative Behavioral Health Services

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Hutchinson, MN
  • NPI 1730992090
  Medicare reassignment Care Compare group
• Mindfully Healing Inc.

  • Mental Health Counselor
  • Spring Park, MN
  • NPI 1235757600
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1564704000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1749168000000",
    "number": "1992350367",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 13",
            "city": "WRENSHALL",
            "state": "MN",
            "postal_code": "557970013",
            "telephone_number": "218-409-7508"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4154 SHORELINE DR STE 202",
            "city": "SPRING PARK",
            "state": "MN",
            "postal_code": "553845610",
            "telephone_number": "952-491-9450"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7501 80th St S",
            "address_purpose": "LOCATION",
            "city": "Cottage Grove",
            "state": "MN",
            "postal_code": "550163020",
            "country_code": "US",
            "telephone_number": "218-409-7508",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TIBBETTS",
        "first_name": "KELLY",
        "middle_name": "JEAN",
        "credential": "LICSW",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2019-08-02",
        "last_updated": "2025-06-06",
        "certification_date": "2025-06-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "22636",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Seniors Care Services LLC
• SP Services (Spring Park Pharmacy)
• SP Services (Spring Park Pharmacy LTC)
• Thomas G Stocks, MD
• TCM Wellness Clinic
• Mary Moe Trites, MD
• Aaron Tsay
• Urology Associates, LTD.
• Dantel Weaver, DDS
• Benedict J Weinbeck III, MA

• Clinical Social Worker in Spring Park, MN
• Providers in Spring Park, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.