Healthcare Provider Details

I. General information

NPI: 1801538889
Provider Name (Legal Business Name): CRYSTAL MARIE SMALLEY LCSW-I, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 CLINIC RD
CHALLIS ID
83226-4824
US

IV. Provider business mailing address

611 CLINIC RD
CHALLIS ID
83226-4824
US

V. Phone/Fax

Practice location:
  • Phone: 208-879-4351
  • Fax: 208-879-5216
Mailing address:
  • Phone: 208-879-4351
  • Fax: 208-879-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6971952
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: