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General NPI Number Information
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NPI Number | 1497015143
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Entity Type | Individual
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Provider Name | ANGELA K KELLY LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/28/2012
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Last Update Date | 08/05/2016
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Provider Practice Location Address
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Address Line | 822 WASHINGTON ST
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City | MONTPELIER
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State | ID
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Zip | 83254-1423
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Country | US
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Telephone | 208-847-4464
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Fax |
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Provider Business Mailing Address
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Address Line | 1675 FOXMORE ST
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City | POCATELLO
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State | ID
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Zip | 83204-4677
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Country | US
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Telephone | 208-317-2347
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-35978
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License Number State | ID
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