Individual
SHASTA LEE HARDEE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LMSW-37764
Contact information
Practice address
2235 E 25TH ST, IDAHO FALLS, ID 83404
(208) 643-2832
(085) 382-2332
Mailing address
1080 BOWER DR, IDAHO FALLS, ID 83404-5151
(208) 680-6135
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
LMSW-37764
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002648300
—
ID
05
—
807375600
—
ID
Enumeration date
05/14/2008
Last updated
06/07/2018
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