Provider Demographics
NPI:1508554940
Name:ICARE CENTER FOR CHANGE
Entity Type:Organization
Organization Name:ICARE CENTER FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNS
Authorized Official - Phone:208-918-2473
Mailing Address - Street 1:1689 E 4000 N
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-5647
Mailing Address - Country:US
Mailing Address - Phone:208-918-2473
Mailing Address - Fax:
Practice Address - Street 1:1689 E 4000 N
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316-5647
Practice Address - Country:US
Practice Address - Phone:208-918-2473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ICARE TELECARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1558567107Medicaid