Healthcare Provider Details

I. General information

NPI: 1265363253
Provider Name (Legal Business Name): SHANNON TROY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9482 W FAIRVIEW AVE
BOISE ID
83704-8101
US

IV. Provider business mailing address

1433 N ELLINGTON PL
EAGLE ID
83616-4079
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-3230
  • Fax:
Mailing address:
  • Phone: 208-602-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC5381711
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: