Provider Demographics
NPI:1902558638
Name:WARD, KELCEYMARIE (MED)
Entity Type:Individual
Prefix:
First Name:KELCEYMARIE
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3664 S YVONNE WAY
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-1256
Mailing Address - Country:US
Mailing Address - Phone:208-243-7993
Mailing Address - Fax:
Practice Address - Street 1:3664 S YVONNE WAY
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-1256
Practice Address - Country:US
Practice Address - Phone:208-243-7993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician