Provider Demographics
NPI:1083841928
Name:EHMANN, SHELLY RAE (MC, LPC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:EHMANN
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2832 VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5549
Mailing Address - Country:US
Mailing Address - Phone:928-242-8729
Mailing Address - Fax:928-368-8720
Practice Address - Street 1:105 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-2817
Practice Address - Country:US
Practice Address - Phone:928-524-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-2472101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional