Provider Demographics
NPI:1629679048
Name:ISRAELSEN, SHAWN ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ROBERT
Last Name:ISRAELSEN
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 1:2275 W. BROADWAY ST #G
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2902
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:208-524-8004
Practice Address - Street 1:2265 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2996
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:208-534-8004
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-18733104100000X
IDLMSW-40331104100000X
UT8722060-35021041C0700X
UT8722060-3502CSW1041C0700X
IDLCSW-44276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical