Provider Demographics
NPI:1922668748
Name:MCKELLAR, JUSTINE PAULINE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:PAULINE
Last Name:MCKELLAR
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 1:11239 N CRUSADER ST
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8705
Mailing Address - Country:US
Mailing Address - Phone:808-286-1293
Mailing Address - Fax:
Practice Address - Street 1:7905 N MEADOWLARK WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-772-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38734104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker