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General NPI Number Information
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NPI Number | 1780209288
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Entity Type | Individual
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Provider Name | SHAWNA EDDY EDDY KISSELL PSYCHOLOGIST, LCPC
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Gender | Female
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Dates
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Enumeration Date | 06/10/2020
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Last Update Date | 06/10/2020
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Provider Practice Location Address
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Address Line | 541 W 3RD ST
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City | WEISER
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State | ID
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Zip | 83672-1813
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Country | US
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Telephone | 208-549-0995
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Fax |
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Provider Business Mailing Address
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Address Line | 541 W 3RD ST
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City | WEISER
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State | ID
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Zip | 83672-1813
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Country | US
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Telephone | 208-549-0995
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PS007800L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 5061
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCPC
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License Number State | ID
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