Healthcare Provider Details

I. General information

NPI: 1629679048
Provider Name (Legal Business Name): SHAWN ROBERT ISRAELSEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 W BROADWAY ST
IDAHO FALLS ID
83402-2996
US

IV. Provider business mailing address

2275 W. BROADWAY ST #G
IDAHO FALLS ID
83402-2902
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax: 208-534-8004
Mailing address:
  • Phone: 208-524-7400
  • Fax: 208-524-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCSW-44276
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-18733
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-40331
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8722060-3502
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8722060-3502CSW
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: