1740570704 NPI number — KEELY ELISE ADAMS LCPC

Table of content: KEELY ELISE ADAMS LCPC (NPI 1740570704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740570704 NPI number — KEELY ELISE ADAMS LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADAMS
Provider First Name:
KEELY
Provider Middle Name:
ELISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COVERDELL
Provider Other First Name:
KEELY
Provider Other Middle Name:
ELISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740570704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4665 S ALMA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-9168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-800-9599
Provider Business Mailing Address Fax Number:
208-277-1817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4665 S ALMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-9168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-800-9599
Provider Business Practice Location Address Fax Number:
208-277-1817
Provider Enumeration Date:
04/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  6157 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1740570704 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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