Provider Demographics
NPI:1609945831
Name:SHADE, MARIE ANN (LCPC)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:ANN
Last Name:SHADE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:A
Other - Last Name:SHADE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:684 N 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:85702-5458
Mailing Address - Country:US
Mailing Address - Phone:208-343-6636
Mailing Address - Fax:208-389-1474
Practice Address - Street 1:684 N 9TH STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:85702-5458
Practice Address - Country:US
Practice Address - Phone:208-343-6636
Practice Address - Fax:208-389-1474
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC44101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ1687OtherBLUE CROSS
ID000010016630OtherREGENCE BLUE SHIELD