Healthcare Provider Details

I. General information

NPI: 1275032815
Provider Name (Legal Business Name): SUSAN KAYE NIELSEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E 25TH ST
IDAHO FALLS ID
83404-7549
US

IV. Provider business mailing address

4621 GEMMETT CREEK RD
IDAHO FALLS ID
83401-5021
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax: 208-528-2945
Mailing address:
  • Phone: 208-419-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-37165
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: