Individual
TERRELL L. KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
120 E HOWARD ST, DRIGGS, ID 83422-5112
(208) 354-6317
Mailing address
120 E HOWARD ST, DRIGGS, ID 83422-5112
(208) 354-6317
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
LCSW-431
ID
1041C0700X
Clinical Social Worker
LCSW-454
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000010015891
BLUE SHIELD
ID
01
—
L4314
BLUE CROSS
ID
Enumeration date
12/05/2006
Last updated
07/08/2007
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