Healthcare Provider Details

I. General information

NPI: 1699032839
Provider Name (Legal Business Name): CRYSTAL KILGORE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 S WASHINGTON ST STE A
MOSCOW ID
83843-3055
US

IV. Provider business mailing address

828 S WASHINGTON ST STE A
MOSCOW ID
83843-3055
US

V. Phone/Fax

Practice location:
  • Phone: 208-883-7766
  • Fax:
Mailing address:
  • Phone: 208-883-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-5674
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: