Provider Demographics
NPI:1326212002
Name:SHULDBERG, SHON LORIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SHON
Middle Name:LORIN
Last Name:SHULDBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E 17TH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6273
Mailing Address - Country:US
Mailing Address - Phone:208-523-0787
Mailing Address - Fax:
Practice Address - Street 1:1277 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6126
Practice Address - Country:US
Practice Address - Phone:208-523-0787
Practice Address - Fax:208-523-3175
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-288631041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical