Healthcare Provider Details

I. General information

NPI: 1811413750
Provider Name (Legal Business Name): CARRIE JANE LEELING LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARRIE JANE ROBERTS LCSW

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 OREGON ST
KELLOGG ID
83837-5018
US

IV. Provider business mailing address

PO BOX 331
SMELTERVILLE ID
83868-0331
US

V. Phone/Fax

Practice location:
  • Phone: 208-951-2767
  • Fax:
Mailing address:
  • Phone: 208-951-2767
  • Fax: 208-225-4238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-36779
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-40791
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: