Organization
SHADOW AND LIGHT WELLNESS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SAMANTHA DARLENE HODGE-TRACY LPC (OWNER/COUNSELOR)
(208) 227-3571
Entity
Organization
Contact information
Practice address
919 S 25TH E, AMMON, ID 83406-5731
(208) 227-3571
Mailing address
785 TERRACE DR, IDAHO FALLS, ID 83402-3113
(208) 227-3571
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Enumeration date
02/11/2025
Last updated
02/11/2025
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