Provider Demographics
NPI:1871554584
Name:CLUBB, SHANE M (MA, LCPC)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:M
Last Name:CLUBB
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 E STATE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2342
Mailing Address - Country:US
Mailing Address - Phone:208-994-3599
Mailing Address - Fax:208-473-2206
Practice Address - Street 1:39 E STATE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2342
Practice Address - Country:US
Practice Address - Phone:208-994-3599
Practice Address - Fax:208-473-2206
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3989101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health