Provider Demographics
NPI:1659420693
Name:BERMENSOLO, MARY KELLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KELLEEN
Last Name:BERMENSOLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S ORCHARD ST
Mailing Address - Street 2:STE 132
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1288
Mailing Address - Country:US
Mailing Address - Phone:208-412-6683
Mailing Address - Fax:208-888-2215
Practice Address - Street 1:410 S ORCHARD ST
Practice Address - Street 2:STE 132
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1288
Practice Address - Country:US
Practice Address - Phone:208-412-6683
Practice Address - Fax:208-888-2215
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW4921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical