Provider Demographics
NPI:1578115754
Name:RED ELK, TAYLOR L (LCPC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:L
Last Name:RED ELK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 W BROADWAY ST.
Mailing Address - Street 2:SUITE G
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:208-524-8004
Practice Address - Street 1:2275 W BROADWAY ST STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-8325101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional