Provider Demographics
NPI:1497202238
Name:SPROLES, KATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SPROLES
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 1:404 W CAMERON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2111
Mailing Address - Country:US
Mailing Address - Phone:208-215-1756
Mailing Address - Fax:208-545-6958
Practice Address - Street 1:404 W CAMERON AVE
Practice Address - Street 2:STE 101
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2111
Practice Address - Country:US
Practice Address - Phone:208-215-1756
Practice Address - Fax:208-545-6958
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-38419101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health