Provider Demographics
NPI:1154670420
Name:BINGHAM, KARLY DAWN (BS)
Entity Type:Individual
Prefix:
First Name:KARLY
Middle Name:DAWN
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:KARLY
Other - Middle Name:DAWN
Other - Last Name:LOUDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3474 N VOLCANIC AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6152
Mailing Address - Country:US
Mailing Address - Phone:208-419-5688
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-02
Last Update Date:2012-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker