Provider Demographics
NPI:1710244371
Name:KLOSTERMAN, LAURA LEE SHEPHERD (LCPC)
Entity Type:Individual
Prefix:
First Name:LAURA LEE
Middle Name:SHEPHERD
Last Name:KLOSTERMAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 LOMAX ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2634
Mailing Address - Country:US
Mailing Address - Phone:208-524-3733
Mailing Address - Fax:208-524-3738
Practice Address - Street 1:548 LOMAX ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2634
Practice Address - Country:US
Practice Address - Phone:208-524-3733
Practice Address - Fax:208-524-3738
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3937101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor