Healthcare Provider Details

I. General information

NPI: 1427409051
Provider Name (Legal Business Name): KAVIN BRANHAM LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 S 1ST E STE 103
REXBURG ID
83440-1965
US

IV. Provider business mailing address

PO BOX 18
SAINT ANTHONY ID
83445-0018
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4900
  • Fax: 208-624-4030
Mailing address:
  • Phone: 208-356-4900
  • Fax: 208-624-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-7894
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: