Healthcare Provider Details

I. General information

NPI: 1629235353
Provider Name (Legal Business Name): KELLIE HUMPHERYS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6933 W EMERALD ST
BOISE ID
83704-8616
US

IV. Provider business mailing address

6933 W EMERALD ST
BOISE ID
83704-8616
US

V. Phone/Fax

Practice location:
  • Phone: 208-321-0634
  • Fax: 208-321-1082
Mailing address:
  • Phone: 208-321-0634
  • Fax: 208-321-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW-37609
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: