Provider Demographics
NPI:1285642520
Name:KELLICUT, RAQUEL ANGELA (MA)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:ANGELA
Last Name:KELLICUT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LINCOLN WAY STE 500
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2391
Mailing Address - Country:US
Mailing Address - Phone:208-667-8474
Mailing Address - Fax:208-665-5704
Practice Address - Street 1:1420 LINCOLN WAY STE 500
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2391
Practice Address - Country:US
Practice Address - Phone:208-667-8474
Practice Address - Fax:208-665-5704
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 137101Y00000X
WALH00003616101Y00000X
IDLMFT 3069106H00000X
WALF00000961106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist