Provider Demographics
NPI:1942820733
Name:HUTCHINSON, SHELLEY J (EDM)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:J
Last Name:HUTCHINSON
Suffix:
Gender:F
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3322
Mailing Address - Country:US
Mailing Address - Phone:208-553-5367
Mailing Address - Fax:
Practice Address - Street 1:701 21ST ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3322
Practice Address - Country:US
Practice Address - Phone:208-553-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID015405Medicaid