MEDICARE: MS. SHANNA DEE PICKREN L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW-30318	ID

General Provider Information

NPI Number	:	1356722821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNA DEE PICKREN L.C.S.W.

Provider Business Mailing Address
First Line	:	1818 N 9TH ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-3619
Country	:	US
Telephone Number	:	208-353-7160
Fax Number	:

Provider Business Practice Location Address
First Line	:	7161 W POTOMAC DR
Second Line	:	STE. A
City	:	BOISE
State	:	ID
Zip	:	83704-9148
Country	:	US
Telephone Number	:	208-908-6399
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	06/10/2015

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