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General NPI Number Information
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NPI Number | 1174756290
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Entity Type | Individual
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Provider Name | MICHAEL SHANE OLDFIELD I LMSW
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Gender | Male
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Dates
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Enumeration Date | 08/24/2009
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Last Update Date | 08/24/2009
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Provider Practice Location Address
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Address Line | 2420 E 25TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7549
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Country | US
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Telephone | 208-542-1026
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Fax |
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Provider Business Mailing Address
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Address Line | 2420 E 25TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7549
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Country | US
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Telephone | 208-542-1026
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 29470
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License Number State | ID
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