Provider Demographics
NPI:1417398736
Name:KELLEY, RACHEL M (LCSW)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 E 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6235
Mailing Address - Country:US
Mailing Address - Phone:208-556-3616
Mailing Address - Fax:208-202-2769
Practice Address - Street 1:1337 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-556-3616
Practice Address - Fax:208-202-2769
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-32901104100000X
IDLCSW354791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker