Provider Demographics
NPI:1386901627
Name:SEBREROS, RONALD KYLE I (LCSW)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:KYLE
Last Name:SEBREROS
Suffix:I
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 ALAN ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5801
Mailing Address - Country:US
Mailing Address - Phone:208-528-7655
Mailing Address - Fax:208-542-9390
Practice Address - Street 1:2100 ALAN ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5801
Practice Address - Country:US
Practice Address - Phone:208-528-7655
Practice Address - Fax:208-524-9390
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-34256104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker