Provider Demographics
NPI:1497046718
Name:KELSCH, MARK (LMSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KELSCH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2267 TETON PLZ
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6486
Mailing Address - Country:US
Mailing Address - Phone:208-524-4953
Mailing Address - Fax:208-524-7335
Practice Address - Street 1:2267 TETON PLZ
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6486
Practice Address - Country:US
Practice Address - Phone:208-522-0140
Practice Address - Fax:208-524-7335
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-37136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1346368198Medicaid