Provider Demographics
NPI:1295354355
Name:CHATTERTON, KELLY LYNN (ICADC, CADC, SAP)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LYNN
Last Name:CHATTERTON
Suffix:
Gender:F
Credentials:ICADC, CADC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 COLE ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4955
Mailing Address - Country:US
Mailing Address - Phone:208-339-4632
Mailing Address - Fax:
Practice Address - Street 1:809 N ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-2803
Practice Address - Country:US
Practice Address - Phone:208-339-4632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID122928101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)