Provider Demographics
NPI:1790454478
Name:SHANTI, NADAMAYI (LPC)
Entity Type:Individual
Prefix:
First Name:NADAMAYI
Middle Name:
Last Name:SHANTI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 E HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8309
Mailing Address - Country:US
Mailing Address - Phone:208-615-8755
Mailing Address - Fax:
Practice Address - Street 1:1498 E HOLLY ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-8309
Practice Address - Country:US
Practice Address - Phone:208-615-8755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health