Provider Demographics
NPI:1659797090
Name:PENDLETON, KRISTY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:ANN
Last Name:PENDLETON
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 1:3656 E VISION DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5045
Mailing Address - Country:US
Mailing Address - Phone:208-313-7449
Mailing Address - Fax:
Practice Address - Street 1:1301 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6273
Practice Address - Country:US
Practice Address - Phone:208-538-3122
Practice Address - Fax:208-881-5295
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-34365101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health