Provider Demographics
NPI:1437264819
Name:MCKELL, GARY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:MCKELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5618
Mailing Address - Country:US
Mailing Address - Phone:208-522-5032
Mailing Address - Fax:
Practice Address - Street 1:1477 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5618
Practice Address - Country:US
Practice Address - Phone:208-522-5032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374809Medicare ID - Type Unspecified