Healthcare Provider Details

I. General information

NPI: 1982076410
Provider Name (Legal Business Name): WILLOW R KENYON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 N 12TH ST
PLUMMER ID
83851-0388
US

IV. Provider business mailing address

PO BOX 388
PLUMMER ID
83851-0388
US

V. Phone/Fax

Practice location:
  • Phone: 208-686-1931
  • Fax: 208-686-0213
Mailing address:
  • Phone: 208-686-1931
  • Fax: 208-686-0213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-37482
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: