Provider Demographics
NPI:1497386585
Name:NEELY, KIM ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANN
Last Name:NEELY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4047
Mailing Address - Country:US
Mailing Address - Phone:208-746-4097
Mailing Address - Fax:208-746-2294
Practice Address - Street 1:1720 18TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4047
Practice Address - Country:US
Practice Address - Phone:208-746-4097
Practice Address - Fax:208-746-2294
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID29893101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID29893OtherLMSW LICENSE