Provider Demographics
NPI:1215112453
Name:MILES, SHANNON MARIE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MILES
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E SHORE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6583
Mailing Address - Country:US
Mailing Address - Phone:208-761-7677
Mailing Address - Fax:
Practice Address - Street 1:325 E SHORE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6583
Practice Address - Country:US
Practice Address - Phone:208-761-7677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38858106H00000X
IDLMFT4551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID46-3244838OtherEIN