Provider Demographics
NPI:1427837228
Name:WALLENTINE, SHANELL (LPC)
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:WALLENTINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2886 S TAGISH WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9190
Mailing Address - Country:US
Mailing Address - Phone:208-272-1563
Mailing Address - Fax:
Practice Address - Street 1:3061 S MERIDIAN RD STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7962
Practice Address - Country:US
Practice Address - Phone:208-620-5399
Practice Address - Fax:208-576-6915
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional