Provider Demographics
NPI:1407209497
Name:CLARK, KATEY STROUD (LMSW)
Entity Type:Individual
Prefix:
First Name:KATEY
Middle Name:STROUD
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 N COLE RD STE 225
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5966
Mailing Address - Country:US
Mailing Address - Phone:208-841-4890
Mailing Address - Fax:
Practice Address - Street 1:2995 N COLE RD STE 225
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5966
Practice Address - Country:US
Practice Address - Phone:208-841-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW - 31618101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor