Provider Demographics
NPI:1558657098
Name:BROWN, KELLIE J (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:J
Last Name:BROWN
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 1:2001 S WOODRUFF AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-529-4673
Mailing Address - Fax:208-529-4676
Practice Address - Street 1:2001 S. WOODRUFF STE. 6
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-529-4673
Practice Address - Fax:208-529-4676
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-30644101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor