Provider Demographics
NPI:1932323045
Name:BRONCHO, KRISTY LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:LEE
Last Name:BRONCHO
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:RR 6 BOX 918
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-9549
Mailing Address - Country:US
Mailing Address - Phone:208-637-8032
Mailing Address - Fax:
Practice Address - Street 1:MISSION ROAD BLDING 248
Practice Address - Street 2:FORT HALL INDIAN AGENCY
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203
Practice Address - Country:US
Practice Address - Phone:208-237-5631
Practice Address - Fax:208-237-5796
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-245061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical