Provider Demographics
NPI:1497015143
Name:KELLY, ANGELA K (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:K
Last Name:KELLY
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 1:1675 FOXMORE ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4677
Mailing Address - Country:US
Mailing Address - Phone:208-317-2347
Mailing Address - Fax:
Practice Address - Street 1:822 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1423
Practice Address - Country:US
Practice Address - Phone:208-847-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-359781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical