Healthcare Provider Details

I. General information

NPI: 1396171153
Provider Name (Legal Business Name): KRISTI L NELSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 JENNIE LEE DR
IDAHO FALLS ID
83404-6159
US

IV. Provider business mailing address

1908 JENNIE LEE DR
IDAHO FALLS ID
83404-6159
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-7074
  • Fax: 208-970-6188
Mailing address:
  • Phone: 208-520-7074
  • Fax: 208-970-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW33173
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: