Provider Demographics
NPI:1841855798
Name:OSBORNE, SHELLY MARIE (LCPC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:MARIE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:647 POLE LINE RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4083
Mailing Address - Country:US
Mailing Address - Phone:208-860-8203
Mailing Address - Fax:
Practice Address - Street 1:112 SHOSHONE ST E STE 2
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6185
Practice Address - Country:US
Practice Address - Phone:208-860-8203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5757101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health