Healthcare Provider Details

I. General information

NPI: 1508798596
Provider Name (Legal Business Name): CHRISTINE LEDBETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S MAIN ST
SODA SPRINGS ID
83276-5215
US

IV. Provider business mailing address

1486 HAWKER EXT
SODA SPRINGS ID
83276-5666
US

V. Phone/Fax

Practice location:
  • Phone: 208-221-1196
  • Fax:
Mailing address:
  • Phone: 208-221-1196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCPC-5126
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: