Provider Demographics
NPI:1285954313
Name:NIELSEN, SHAWN GARY (LMSW)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:GARY
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 W RIVER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7083
Mailing Address - Country:US
Mailing Address - Phone:208-338-4699
Mailing Address - Fax:208-322-4722
Practice Address - Street 1:1276 W RIVER ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7083
Practice Address - Country:US
Practice Address - Phone:208-338-4699
Practice Address - Fax:208-322-4722
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW 245441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical