Healthcare Provider Details

I. General information

NPI: 1396277000
Provider Name (Legal Business Name): KIMBERLY ANN STOCKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 S 9TH AVE STE 103
CALDWELL ID
83605-5072
US

IV. Provider business mailing address

524 S 9TH AVE STE 103
CALDWELL ID
83605-5072
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-2144
  • Fax: 208-454-2149
Mailing address:
  • Phone: 208-454-2144
  • Fax: 208-454-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-6699
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: