Provider Demographics
NPI:1114570892
Name:WELCH, SHANNON RENEE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:WELCH
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 1:19476 LORI DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-9526
Mailing Address - Country:US
Mailing Address - Phone:208-922-8348
Mailing Address - Fax:
Practice Address - Street 1:19802 WILDERNESS DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-8078
Practice Address - Country:US
Practice Address - Phone:208-922-8348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician