Provider Demographics
NPI:1982290938
Name:ELDER, KERRY
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:ELDER
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 1:12514 W MACUMBO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5169
Mailing Address - Country:US
Mailing Address - Phone:208-850-3542
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST STE 128
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1288
Practice Address - Country:US
Practice Address - Phone:208-850-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional