Provider Demographics
NPI:1427473594
Name:BACH, SHAUNNA (MS,LPC,NCC,)
Entity type:Individual
Prefix:
First Name:SHAUNNA
Middle Name:
Last Name:BACH
Suffix:
Gender:F
Credentials:MS,LPC,NCC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3999 W COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7113
Mailing Address - Country:US
Mailing Address - Phone:208-629-6850
Mailing Address - Fax:
Practice Address - Street 1:4060 E CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6481
Practice Address - Country:US
Practice Address - Phone:208-629-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional