Provider Demographics
NPI:1073205282
Name:BURRIS, SHELLIE (LMSW)
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 HUCKLEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5588
Mailing Address - Country:US
Mailing Address - Phone:208-695-1678
Mailing Address - Fax:
Practice Address - Street 1:1125 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6210
Practice Address - Country:US
Practice Address - Phone:208-505-9990
Practice Address - Fax:208-944-9655
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker