Provider Demographics
NPI:1609159797
Name:BRANHAM, SHANNA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:
Last Name:BRANHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1933
Mailing Address - Country:US
Mailing Address - Phone:208-371-3362
Mailing Address - Fax:
Practice Address - Street 1:915 PARKCENTRE WAY
Practice Address - Street 2:SUITE 7
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1745
Practice Address - Country:US
Practice Address - Phone:208-442-7791
Practice Address - Fax:208-442-7792
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-316361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical