Healthcare Provider Details

I. General information

NPI: 1144672635
Provider Name (Legal Business Name): SHANNON MOSKITIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 N CLOVERDALE RD
BOISE ID
83713-2423
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-8000
  • Fax: 208-706-8001
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-40108
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: