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General NPI Number Information
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NPI Number | 1205571668
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Entity Type | Organization
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Legal Business Name | CLEAR SOURCE THERAPY AND CLINICAL RESOURCE CENTER LLC
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Dates
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Enumeration Date | 04/30/2022
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Last Update Date | 03/15/2023
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Provider Practice Location Address
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Address Line | 392 FALLS AVE
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City | TWIN FALLS
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State | ID
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Zip | 83301-3373
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Country | US
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Telephone | 208-749-3475
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Fax | 208-450-2408
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Provider Business Mailing Address
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Address Line | 392 FALLS AVE
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City | TWIN FALLS
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State | ID
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Zip | 83301-3373
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Country | US
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Telephone | 208-749-3475
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Fax | 208-450-2408
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Authorized Official
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Title or Position | OWNER
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Name | EZEKIEL KELSEY
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Credential | M.S., CCC-SLP
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Telephone | 208-320-5686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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