Provider Demographics
NPI:1194992545
Name:HARDEE, SHASTA LEE (LMSW-37764)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:LEE
Last Name:HARDEE
Suffix:
Gender:F
Credentials:LMSW-37764
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 BOWER DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5151
Mailing Address - Country:US
Mailing Address - Phone:208-680-6135
Mailing Address - Fax:
Practice Address - Street 1:2235 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-643-2832
Practice Address - Fax:085-382-2332
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-37764104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648300Medicaid
ID807375600Medicaid