Healthcare Provider Details

I. General information

NPI: 1396419446
Provider Name (Legal Business Name): SHAWKAREE LENAE MATTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAWKAREE LENAE DOVER

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 N MEADOWLARK WAY STE C&D
COEUR D ALENE ID
83815-5041
US

IV. Provider business mailing address

12673 N KENOSHA LN APT 302
RATHDRUM ID
83858-7458
US

V. Phone/Fax

Practice location:
  • Phone: 208-618-2593
  • Fax:
Mailing address:
  • Phone: 509-760-5378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: