Individual
SHANE WEIDEMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2007 E QUAIL RUN RD, EMMETT, ID 83617-5059
(208) 365-5445
Mailing address
2305 VALLEY VIEW DR, WEISER, ID 83672-1245
(208) 540-0226
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LPC-6270
ID
Other
Enumeration date
09/19/2016
Last updated
09/19/2016
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