Provider Demographics
NPI:1043480403
Name:SHOUP, MARIZZA
Entity Type:Individual
Prefix:MS
First Name:MARIZZA
Middle Name:
Last Name:SHOUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 ALBION AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1818
Mailing Address - Country:US
Mailing Address - Phone:208-878-4155
Mailing Address - Fax:208-878-1042
Practice Address - Street 1:1358 ALBION AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1818
Practice Address - Country:US
Practice Address - Phone:208-878-4155
Practice Address - Fax:208-878-1042
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-01
Last Update Date:2008-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8075217171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator