Healthcare Provider Details

I. General information

NPI: 1497015143
Provider Name (Legal Business Name): ANGELA K KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 WASHINGTON ST
MONTPELIER ID
83254-1423
US

IV. Provider business mailing address

1675 FOXMORE ST
POCATELLO ID
83204-4677
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-4464
  • Fax:
Mailing address:
  • Phone: 208-317-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-35978
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: