Healthcare Provider Details

I. General information

NPI: 1841868148
Provider Name (Legal Business Name): CRYSTAL ANN CHEROMIAH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 COMMERCE DRIVE STE. 100
SMELTERVILLE ID
83868
US

IV. Provider business mailing address

25 JACOBS GULCH RD
KELLOGG ID
83837-2023
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-1221
  • Fax: 208-783-1342
Mailing address:
  • Phone: 208-784-1221
  • Fax: 208-784-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-44387
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: