Healthcare Provider Details

I. General information

NPI: 1326409913
Provider Name (Legal Business Name): JOHNATHAN KOELSCH LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 CURLEW DR
AMMON ID
83406-4850
US

IV. Provider business mailing address

PO BOX 2106
IDAHO FALLS ID
83403-2106
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-5319
  • Fax: 208-523-5627
Mailing address:
  • Phone: 208-523-5319
  • Fax: 208-523-5627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLMSW-34382
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-38371
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: