Provider Demographics
NPI:1538596226
Name:LAULU, SHANTAL LEE (LCPC, CADC)
Entity type:Individual
Prefix:MRS
First Name:SHANTAL
Middle Name:LEE
Last Name:LAULU
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3312
Mailing Address - Country:US
Mailing Address - Phone:208-234-4722
Mailing Address - Fax:
Practice Address - Street 1:110 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3312
Practice Address - Country:US
Practice Address - Phone:208-234-4722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5335101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health