Provider Demographics
NPI:1952061095
Name:KELLIS, KENDRA (LAMFT)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:KELLIS
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3531
Mailing Address - Country:US
Mailing Address - Phone:208-918-2019
Mailing Address - Fax:
Practice Address - Street 1:1407 N 13TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3531
Practice Address - Country:US
Practice Address - Phone:208-918-2019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFTA-8585106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist