Healthcare Provider Details

I. General information

NPI: 1578495727
Provider Name (Legal Business Name): ELLON CHASE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

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

420 S CUTLER AVE
SUGAR CITY ID
83448-1142
US

IV. Provider business mailing address

420 S CUTLER AVE
SUGAR CITY ID
83448-1142
US

V. Phone/Fax

Practice location:
  • Phone: 208-351-6580
  • Fax:
Mailing address:
  • Phone: 208-351-6580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2571394
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: