Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1174833966 |
---|---|
Provider Name | Kimberly Sue Kelly |
First Address | Idaho Falls, ID 83401-5299 |
Second Address | Idaho Falls, ID 83401-5299 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/10/2010 |
Last Update Date | 14/10/2010 |