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General NPI Number Information
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NPI Number | 1194992545
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Entity Type | Individual
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Provider Name | SHASTA LEE HARDEE LMSW-37764
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Gender | Female
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Dates
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Enumeration Date | 05/14/2008
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Last Update Date | 06/07/2018
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Provider Practice Location Address
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Address Line | 2235 E 25TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-643-2832
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Fax | 85-382-2332
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Provider Business Mailing Address
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Address Line | 1080 BOWER DR
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City | IDAHO FALLS
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State | ID
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Zip | 83404-5151
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Country | US
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Telephone | 208-680-6135
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | LMSW-37764
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License Number State | ID
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