Healthcare Provider Details

I. General information

NPI: 1083143382
Provider Name (Legal Business Name): KIMBERLY LYNN SHELDEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 09/17/2023
Certification Date: 09/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 IRONWOOD PL STE B
COEUR D ALENE ID
83814-2487
US

IV. Provider business mailing address

2025 W PARK PL
COEUR D ALENE ID
83814-2787
US

V. Phone/Fax

Practice location:
  • Phone: 208-769-4222
  • Fax: 208-667-7557
Mailing address:
  • Phone: 208-769-4222
  • Fax: 208-667-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-36782
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-39199
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: