Basic Information
| Provider Information | |||||||||
| NPI: | 1184917346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LAVON | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2377 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832062377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326260 | ||||||||
| FaxNumber: | 2082326259 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 W CENTER ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832044205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326260 | ||||||||
| FaxNumber: | 2082326259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2011 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LSW 29478 | ID | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LCSW-33226 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.