Provider Demographics
NPI:1891146056
Name:STUBBLEFIELD, SHANA L (LMSW)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:L
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3319
Mailing Address - Country:US
Mailing Address - Phone:208-917-0561
Mailing Address - Fax:
Practice Address - Street 1:611 HOOPES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-6106
Practice Address - Country:US
Practice Address - Phone:208-557-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID35214101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health