MEDICARE: SHELLY RAE EHMANN MC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC-2472	AZ

General Provider Information

NPI Number	:	1083841928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY RAE EHMANN MC, LPC

Provider Business Mailing Address
First Line	:	2832 VIEW WAY
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5549
Country	:	US
Telephone Number	:	928-242-8729
Fax Number	:	928-368-8720

Provider Business Practice Location Address
First Line	:	105 N 5TH AVE
Second Line	:
City	:	HOLBROOK
State	:	AZ
Zip	:	86025-2817
Country	:	US
Telephone Number	:	928-524-6126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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