Provider Demographics
NPI:1477629590
Name:ELKIN, INGA L (MED, LCPC)
Entity Type:Individual
Prefix:
First Name:INGA
Middle Name:L
Last Name:ELKIN
Suffix:
Gender:F
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 2ND AVE N STE B
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6158
Mailing Address - Country:US
Mailing Address - Phone:208-308-4012
Mailing Address - Fax:208-732-6116
Practice Address - Street 1:202 2ND AVE N STE B
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6158
Practice Address - Country:US
Practice Address - Phone:208-308-4012
Practice Address - Fax:208-732-6116
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149104OtherBLUESHIELD PROVIDER #
IDQ7365OtherPROVIDER # FOR CLINIC