Basic Information
| Provider Information | |||||||||
| NPI: | 1841868148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMBLISS | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 JACOBS GULCH RD | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087841221 | ||||||||
| FaxNumber: | 2087842441 | ||||||||
| Practice Location | |||||||||
| Address1: | 858 COMMERCE DRIVE STE. 100 | ||||||||
| Address2: | |||||||||
| City: | SMELTERVILLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087841221 | ||||||||
| FaxNumber: | 2087831342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-40832 | ID | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.