Healthcare Provider Details

I. General information

NPI: 1184176463
Provider Name (Legal Business Name): KELLY LIND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY STE 477
POCATELLO ID
83201-2744
US

IV. Provider business mailing address

444 HOSPITAL WAY STE 477
POCATELLO ID
83201-2744
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-7832
  • Fax:
Mailing address:
  • Phone: 208-233-7832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-33981
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: