Provider Demographics
NPI:1336426550
Name:PHILLIPS, SHELLEY RAE (LPC)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:RAE
Last Name:PHILLIPS
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 1:2117 E BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6003
Mailing Address - Country:US
Mailing Address - Phone:208-704-9007
Mailing Address - Fax:
Practice Address - Street 1:212 S 11TH ST STE 5
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4000
Practice Address - Country:US
Practice Address - Phone:208-704-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4587101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional