Provider Demographics
NPI:1346708716
Name:KELLS, ROSEMARY THAIR (LPC)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:THAIR
Last Name:KELLS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4680
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-4697
Mailing Address - Country:US
Mailing Address - Phone:208-928-7181
Mailing Address - Fax:
Practice Address - Street 1:141 CITATION WAY UNIT 6
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-5104
Practice Address - Country:US
Practice Address - Phone:208-788-0146
Practice Address - Fax:208-788-1210
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3954101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1942301106Medicaid