Provider Demographics
NPI:1396274056
Name:SANDERS, SHELLY D (LCSW)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:SANDERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 NORTHWEST BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2488
Mailing Address - Country:US
Mailing Address - Phone:208-512-5085
Mailing Address - Fax:800-865-1927
Practice Address - Street 1:1620 NORTHWEST BLVD STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2488
Practice Address - Country:US
Practice Address - Phone:208-512-5085
Practice Address - Fax:800-865-1927
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID396921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID36775OtherLICENSE
ID39692OtherLCSW LICENSE