Healthcare Provider Details

I. General information

NPI: 1639779879
Provider Name (Legal Business Name): KAITLIN MICHELLE CLAYSON M.COUN, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S 4TH AVE
POCATELLO ID
83201-6404
US

IV. Provider business mailing address

420 S 4TH AVE
POCATELLO ID
83201-6404
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax:
Mailing address:
  • Phone: 208-478-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9411385
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: