Provider Demographics
NPI:1700069937
Name:ILI, KAREN O
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:O
Last Name:ILI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E 1ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-2120
Mailing Address - Country:US
Mailing Address - Phone:208-351-4869
Mailing Address - Fax:
Practice Address - Street 1:631 N 200 E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3599
Practice Address - Country:US
Practice Address - Phone:208-356-6975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-259131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical