Healthcare Provider Details

I. General information

NPI: 1639099690
Provider Name (Legal Business Name): KELSEA ELIZABETH ROYER SUDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 EASTLAND DR N
TWIN FALLS ID
83301-8941
US

IV. Provider business mailing address

1102 EASTLAND DR N
TWIN FALLS ID
83301-8941
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-4200
  • Fax: 208-734-1404
Mailing address:
  • Phone: 208-734-4200
  • Fax: 208-734-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13063
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: