Healthcare Provider Details

I. General information

NPI: 1558657098
Provider Name (Legal Business Name): KELLIE J BROWN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 E ST. STE B
IDAHO FALLS ID
83402
US

IV. Provider business mailing address

254 E ST. STE B
IDAHO FALLS ID
83402
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-1854
  • Fax: 208-523-5974
Mailing address:
  • Phone: 208-529-1854
  • Fax: 208-523-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-38215
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: