Provider Demographics
NPI:1205571668
Name:CLEAR SOURCE THERAPY AND CLINICAL RESOURCE CENTER LLC
Entity type:Organization
Organization Name:CLEAR SOURCE THERAPY AND CLINICAL RESOURCE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EZEKIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:208-320-5686
Mailing Address - Street 1:392 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3373
Mailing Address - Country:US
Mailing Address - Phone:208-749-3475
Mailing Address - Fax:208-450-2408
Practice Address - Street 1:392 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3373
Practice Address - Country:US
Practice Address - Phone:208-749-3475
Practice Address - Fax:208-450-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-30
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty