1871554584 NPI number — MR. SHANE M CLUBB M.A., L.C.P.C.

Table of content: MR. SHANE M CLUBB M.A., L.C.P.C. (NPI 1871554584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871554584 NPI number — MR. SHANE M CLUBB M.A., L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLUBB
Provider First Name:
SHANE
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.A., L.C.P.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871554584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 E STATE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-2342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-994-3599
Provider Business Mailing Address Fax Number:
208-473-2206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 E STATE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-994-3599
Provider Business Practice Location Address Fax Number:
208-473-2206
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LCPC-3989 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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