Provider Demographics
NPI:1235344722
Name:GRAY, SHANNON MAUREEN (LMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MAUREEN
Last Name:GRAY
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 1:1848 W STONE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3578
Mailing Address - Country:US
Mailing Address - Phone:208-288-1918
Mailing Address - Fax:208-922-3778
Practice Address - Street 1:190 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634
Practice Address - Country:US
Practice Address - Phone:208-922-9001
Practice Address - Fax:208-922-3778
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-24699104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker