=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023823531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADOW AND LIGHT WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 S 25TH E
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-5731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-227-3571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 785 TERRACE DR
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83402-3113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-227-3571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/COUNSELOR
-----------------------------------------------------
Name | SAMANTHA DARLENE HODGE-TRACY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 208-227-3571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------