Provider Demographics
NPI:1659003697
Name:KELSEY, SHANE RYAN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:RYAN
Last Name:KELSEY
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 DETTERS RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4991
Mailing Address - Country:US
Mailing Address - Phone:208-219-2378
Mailing Address - Fax:
Practice Address - Street 1:531 E 5TH ST
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1469
Practice Address - Country:US
Practice Address - Phone:208-678-3555
Practice Address - Fax:208-678-3556
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8949101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health