Provider Demographics
NPI:1780209288
Name:EDDY KISSELL, SHAWNA EDDY (PSYCHOLOGIST, LCPC)
Entity Type:Individual
Prefix:MS
First Name:SHAWNA
Middle Name:EDDY
Last Name:EDDY KISSELL
Suffix:
Gender:F
Credentials:PSYCHOLOGIST, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-1813
Mailing Address - Country:US
Mailing Address - Phone:208-549-0995
Mailing Address - Fax:
Practice Address - Street 1:541 W 3RD ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-1813
Practice Address - Country:US
Practice Address - Phone:208-549-0995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007800L103T00000X
OR5061103T00000X
IDLCPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist