Provider Demographics
NPI:1174149215
Name:BLAZICEVICH, KELSEY LYNNE (LPC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNNE
Last Name:BLAZICEVICH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4137
Mailing Address - Country:US
Mailing Address - Phone:208-585-3375
Mailing Address - Fax:208-585-6152
Practice Address - Street 1:923 GRANT ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4137
Practice Address - Country:US
Practice Address - Phone:208-585-3375
Practice Address - Fax:208-585-6152
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor